MEDICARE: VITALY NAZAROV MD

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	208000000X	Pediatrics Physician	233988	MA

General Provider Information

NPI Number	:	1811165350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VITALY NAZAROV MD

Provider Business Mailing Address
First Line	:	100 MAPLE AVE STE 1
Second Line	:
City	:	GT BARRINGTON
State	:	MA
Zip	:	01230-1965
Country	:	US
Telephone Number	:	413-528-4047
Fax Number	:	413-528-3407

Provider Business Practice Location Address
First Line	:	100 MAPLE AVE STE 1
Second Line	:
City	:	GT BARRINGTON
State	:	MA
Zip	:	01230-1965
Country	:	US
Telephone Number	:	413-528-4047
Fax Number	:	413-528-3407

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

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	12/17/2014

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