Provider Demographics
NPI:1467425280
Name:VANINOV, EUGENE L (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:L
Last Name:VANINOV
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 1:280 WASHINGTON ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3511
Mailing Address - Country:US
Mailing Address - Phone:617-562-1433
Mailing Address - Fax:617-562-8233
Practice Address - Street 1:280 WASHINGTON ST
Practice Address - Street 2:SUITE 208
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3511
Practice Address - Country:US
Practice Address - Phone:617-562-1433
Practice Address - Fax:617-562-8233
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAG24499Medicare UPIN