Provider Demographics
NPI:1346277696
Name:GORODETSKY, VICTORIA (NP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:GORODETSKY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-1931
Mailing Address - Country:US
Mailing Address - Phone:978-692-1878
Mailing Address - Fax:
Practice Address - Street 1:1200 CENTRE ST
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02131-1011
Practice Address - Country:US
Practice Address - Phone:617-363-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA253142363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP5047OtherBCBSMA
MAGONP5047Medicare ID - Type Unspecified