Provider Demographics
NPI:1346402682
Name:PASHTAN, ITAI MAX (MD)
Entity Type:Individual
Prefix:DR
First Name:ITAI
Middle Name:MAX
Last Name:PASHTAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:L2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-6230
Mailing Address - Fax:617-582-6037
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:L2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-6230
Practice Address - Fax:617-582-6037
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
282N00000X
MA2460732085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125054409OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION