Provider Demographics
NPI:1336117043
Name:DEMOOR, MICHIEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHIEL
Middle Name:M
Last Name:DEMOOR
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 1:800 WASHINGTON ST # 313
Mailing Address - Street 2:TUFTS MEDICAL CENTER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-5067
Mailing Address - Fax:617-636-2354
Practice Address - Street 1:800 WASHINGTON ST # 313
Practice Address - Street 2:TUFTS MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-5067
Practice Address - Fax:617-636-2354
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160252208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ17454OtherBCBS MA
MA3164616Medicaid
MA764607OtherTUFTS HEALTH PLAN
MAA32691Medicare ID - Type Unspecified
MA3164616Medicaid