Provider Demographics
NPI:1083908685
Name:CARDOOS, NATHAN C (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:C
Last Name:CARDOOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:801 ALBANY ST FL G
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 COMMONWEALTH AVE REAR
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1394
Practice Address - Country:US
Practice Address - Phone:617-358-3400
Practice Address - Fax:617-358-3710
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258669207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110103576AMedicaid