Provider Demographics
NPI:1376533562
Name:PALACIOS, IGOR F (MD)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:F
Last Name:PALACIOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-8424
Mailing Address - Fax:617-726-6800
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:GRB 800
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-8424
Practice Address - Fax:617-726-6800
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44809207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0117765Medicaid
MAE05274OtherBCBS MA
MA718363OtherTUFTS HEALTH PLAN
MAE05274Medicare ID - Type Unspecified
MA0117765Medicaid