Healthcare Provider Details

I. General information

NPI: 1609004464
Provider Name (Legal Business Name): DIANA TRISTER D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 W MAIN ST STE 6
NORTHBOROUGH MA
01532-2164
US

IV. Provider business mailing address

290 W MAIN ST STE 6
NORTHBOROUGH MA
01532-2164
US

V. Phone/Fax

Practice location:
  • Phone: 508-501-7017
  • Fax: 508-526-9982
Mailing address:
  • Phone: 508-501-7017
  • Fax: 508-526-9982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number254413
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: