Provider Demographics
NPI:1093755738
Name:HOULIHAN, MARY JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY JANE
Middle Name:
Last Name:HOULIHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:CC 507 C
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-667-5519
Mailing Address - Fax:617-667-1069
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:CC 507 C
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-667-5519
Practice Address - Fax:617-667-1069
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAH50583208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0186058Medicaid
MAE05956Medicare ID - Type Unspecified
MA0186058Medicaid