Provider Demographics
NPI:1154309623
Name:AVERSA, ANTHONY J (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:AVERSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 MERRIMACK ST STE 311
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1779
Mailing Address - Country:US
Mailing Address - Phone:978-691-5690
Mailing Address - Fax:978-691-5693
Practice Address - Street 1:197 LOUDON RD STE 350
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301
Practice Address - Country:US
Practice Address - Phone:978-691-5690
Practice Address - Fax:978-691-5693
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6913174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0106867Y0NH01OtherANTHEM
NHAA25248OtherHARVARDPILGRIM HEALTHCARE
NH80006867Medicaid
NHB86133Medicare UPIN
NHAA25248OtherHARVARDPILGRIM HEALTHCARE