Provider Demographics
NPI:1376533539
Name:WREN, DONNA KHODARAHMI (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:KHODARAHMI
Last Name:WREN
Suffix:
Gender:F
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:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:81 HIGHLAND AVE
Practice Address - Street 2:NORTH SHORE MEDICAL CENTER
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2714
Practice Address - Country:US
Practice Address - Phone:978-354-2815
Practice Address - Fax:978-740-4702
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153785208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3175812Medicaid
MAJ18640OtherBCBS MA
MA153785OtherTUFTS HEALTH PLAN
MAA23344Medicare ID - Type Unspecified
G65368Medicare UPIN