Provider Demographics
NPI:1417030578
Name:EZPELETA, MARIANO L (MD)
Entity Type:Individual
Prefix:
First Name:MARIANO
Middle Name:L
Last Name:EZPELETA
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 1:750 WASHINGTON ST
Mailing Address - Street 2:NEMC BOX #299
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1526
Mailing Address - Country:US
Mailing Address - Phone:617-636-0054
Mailing Address - Fax:617-636-0041
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:NEMC BOX #299
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-0054
Practice Address - Fax:617-636-0041
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA426982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C05196Medicare ID - Type Unspecified
B98794Medicare UPIN