Provider Demographics
NPI:1376821942
Name:VIVIAN, MARK ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALEXANDER
Last Name:VIVIAN
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 1:107 JERSEY ST
Mailing Address - Street 2:APT 10
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4824
Mailing Address - Country:US
Mailing Address - Phone:617-981-9448
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:A2-L1 MEZZANINE, DEPT OF RADIOLOGY, ABDOMINAL IMAGING
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program