Provider Demographics
NPI:1174508352
Name:BENGTSON, JOAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:BENGTSON
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 1:111 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6002
Mailing Address - Country:US
Mailing Address - Phone:857-307-0896
Mailing Address - Fax:
Practice Address - Street 1:850 BOYLSTON ST
Practice Address - Street 2:SUITE 402
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2477
Practice Address - Country:US
Practice Address - Phone:617-732-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53708207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A57239Medicare UPIN