=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992558464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANGUN KAUR RANDHAWA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2024
-----------------------------------------------------
Last Update Date | 03/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 WASHINGTON ST
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02111-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-636-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 266 WAVERLEY ST APT 605
-----------------------------------------------------
City | FRAMINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01702-7614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-738-2555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 3017048
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------