Provider Demographics
NPI:1023375946
Name:ETHERTON, MARK RICHARD
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:ETHERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:WACC 720
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-726-8459
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WACC 720
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-8459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2654362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology