Provider Demographics
NPI:1205827789
Name:TEICH, DOUGLAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:TEICH
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 1:330 BROOKLINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-754-2009
Mailing Address - Fax:617-754-2004
Practice Address - Street 1:330 BROOKLINE AVENUE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-754-2009
Practice Address - Fax:617-754-2004
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA553162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3010287Medicaid
MA3010287Medicaid
A58488Medicare UPIN