Provider Demographics
NPI: | 1477754687 |
---|---|
Name: | KOREN, DORIT (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DORIT |
Middle Name: | |
Last Name: | KOREN |
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: | 55 FRUIT ST |
Mailing Address - Street 2: | YAWKEY BUILDING, SUITE 6C |
Mailing Address - City: | BOSTON |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02114-2621 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 617-726-2909 |
Mailing Address - Fax: | 617-724-0581 |
Practice Address - Street 1: | 55 FRUIT ST |
Practice Address - Street 2: | YAWKEY BUILDING, SUITE 6C |
Practice Address - City: | BOSTON |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02114-2621 |
Practice Address - Country: | US |
Practice Address - Phone: | 617-726-2909 |
Practice Address - Fax: | 617-724-0581 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-05-29 |
Last Update Date: | 2016-12-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD428754 | 208000000X |
IL | 036.130664 | 2080P0205X, 2080P0205X |
MA | 269242 | 2080P0205X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2080P0205X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | S400347271 | Medicare PIN |