Healthcare Provider Details

I. General information

NPI: 1104811900
Provider Name (Legal Business Name): DAVID MARC BLAUSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2005
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PARKWAY VA BOSTON HEALTHCARE SYSTEM
WEST ROXBURY MA
02132
US

IV. Provider business mailing address

1400 VFW PARKWAY VA BOSTON HEALTHCARE SYSTEM
WEST ROXBURY MA
02132
US

V. Phone/Fax

Practice location:
  • Phone: 857-203-6931
  • Fax: 857-203-5680
Mailing address:
  • Phone: 857-203-6931
  • Fax: 857-203-5680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number78218
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number78218
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number78218
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number78218
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number78218
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: