Provider Demographics
NPI:1417995721
Name:AVERBACK, RANDY J (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:J
Last Name:AVERBACK
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 1:500 WARD ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1136
Mailing Address - Country:US
Mailing Address - Phone:781-453-5238
Mailing Address - Fax:
Practice Address - Street 1:500 WARD ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-1136
Practice Address - Country:US
Practice Address - Phone:781-453-5238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57367207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease