MEDICARE: MR. BOAZ ITSHAKY MSOM

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	171100000X	Acupuncturist	002459-1	NY
2	171100000X	Acupuncturist	000258	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20-1244899	OTHER		TAX ID

General Provider Information

NPI Number	:	1730218181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BOAZ ITSHAKY MSOM

Provider Business Mailing Address
First Line	:	286 BEACON RD
Second Line	:
City	:	BETHANY
State	:	CT
Zip	:	06524-3080
Country	:	US
Telephone Number	:	203-393-2773
Fax Number	:

Provider Business Practice Location Address
First Line	:	286 BEACON RD
Second Line	:
City	:	BETHANY
State	:	CT
Zip	:	06524
Country	:	US
Telephone Number	:	203-393-2773
Fax Number	:

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

Provider Enumeration Date	:	03/03/2007
Last Update Date	:	08/11/2018

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Directions to “ MR. BOAZ ITSHAKY MSOM” Practice Location

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