Provider Demographics
NPI:1164438586
Name:MONAGHAN, COLLEEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:A
Last Name:MONAGHAN
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 1:107 MARIVISTA AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-3062
Mailing Address - Country:US
Mailing Address - Phone:781-899-2956
Mailing Address - Fax:
Practice Address - Street 1:75 BICKFORD ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1401
Practice Address - Country:US
Practice Address - Phone:617-971-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205295207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0178641Medicaid
MA0178641Medicaid
H80392Medicare UPIN