MEDICARE: RADHIKA VENUGOPAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	228983	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	228983	OTHER	MA	STATE LIMITED LICENSE

General Provider Information

NPI Number	:	1467661322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RADHIKA VENUGOPAL M.D.

Provider Business Mailing Address
First Line	:	780 BOYLSTON ST
Second Line	:	APT 16 A
City	:	BOSTON
State	:	MA
Zip	:	02199-7820
Country	:	US
Telephone Number	:	617-304-3921
Fax Number	:

Provider Business Practice Location Address
First Line	:	780 BOYLSTON ST
Second Line	:	APT 16 A
City	:	BOSTON
State	:	MA
Zip	:	02199-7820
Country	:	US
Telephone Number	:	617-304-3921
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	12/03/2009

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