Provider Demographics
NPI:1174505259
Name:ALSTON, THEODORE A (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:A
Last Name:ALSTON
Suffix:
Gender:M
Credentials:MD PHD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:GRB 404B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-8980
Practice Address - Fax:617-726-5985
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA56841207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3062350Medicaid
MAJ09899OtherBCBS MA
MA056841OtherTUFTS HEALTH PLAN
MA3062350Medicaid
MA056841OtherTUFTS HEALTH PLAN