Provider Demographics
NPI:1508895673
Name:TANDETNIK, ALLA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLA
Middle Name:
Last Name:TANDETNIK
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 1:1180 BEACON ST FL 8
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3885
Mailing Address - Country:US
Mailing Address - Phone:617-734-2433
Mailing Address - Fax:
Practice Address - Street 1:1180 BEACON ST FL 8
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-734-2433
Practice Address - Fax:617-277-9821
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152738207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3166091Medicaid
MAJ17696Medicare ID - Type Unspecified
MA3166091Medicaid