Provider Demographics
NPI:1477553923
Name:KHARASCH, VIRGINIA S (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:S
Last Name:KHARASCH
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:PO BOX 35825
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-0014
Mailing Address - Country:US
Mailing Address - Phone:617-783-0475
Mailing Address - Fax:617-779-1239
Practice Address - Street 1:30 WARREN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3602
Practice Address - Country:US
Practice Address - Phone:617-783-0475
Practice Address - Fax:617-779-1239
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58960208000000X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3055736Medicaid
J09161Medicare ID - Type Unspecified
MA3055736Medicaid