Provider Demographics
NPI:1255693305
Name:TICONA, LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:TICONA
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 1:761 WORCESTER RD
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-5224
Mailing Address - Country:US
Mailing Address - Phone:508-872-3254
Mailing Address - Fax:
Practice Address - Street 1:801 MASSACHUSETTS AVE
Practice Address - Street 2:CROSSTOWN 6B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2605
Practice Address - Country:US
Practice Address - Phone:617-414-5951
Practice Address - Fax:617-414-9201
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2019-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251665207R00000X
MA262882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110104119AMedicaid