Provider Demographics
NPI:1225037518
Name:RESERVITZ, GEORGE B (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:B
Last Name:RESERVITZ
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 1:300 MT. AUBURN STREET, SUITE 519
Mailing Address - Street 2:SUITE 519
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5600
Mailing Address - Country:US
Mailing Address - Phone:617-547-4400
Mailing Address - Fax:617-576-1076
Practice Address - Street 1:300 MT. AUBURN STREET, SUITE 519
Practice Address - Street 2:SUITE 519
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5600
Practice Address - Country:US
Practice Address - Phone:617-547-4400
Practice Address - Fax:617-576-1076
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA27845208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6172219Medicaid
A30615Medicare UPIN
MAB05015Medicare PIN
MA6172219Medicaid