Provider Demographics
NPI:1477563377
Name:WALTHAM FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:WALTHAM FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PUNYAMURTULA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KISHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-738-4640
Mailing Address - Street 1:59 TEMPLE PL
Mailing Address - Street 2:STE 612
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1307
Mailing Address - Country:US
Mailing Address - Phone:617-264-9764
Mailing Address - Fax:617-264-9763
Practice Address - Street 1:9 HOPE AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2741
Practice Address - Country:US
Practice Address - Phone:781-314-0191
Practice Address - Fax:781-314-0192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty