Provider Demographics
NPI:1043243975
Name:BERKOWITZ, RANDI ELLEN
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:ELLEN
Last Name:BERKOWITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 GARLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1709
Mailing Address - Country:US
Mailing Address - Phone:617-244-0736
Mailing Address - Fax:
Practice Address - Street 1:1200 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-1011
Practice Address - Country:US
Practice Address - Phone:617-325-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150326207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAG91138Medicare UPIN