Provider Demographics
NPI:1558332270
Name:MOTHS-REBROVIC, ELISABETH JOAN (MD)
Entity Type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:JOAN
Last Name:MOTHS-REBROVIC
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 1:415 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2424
Mailing Address - Country:US
Mailing Address - Phone:617-287-8000
Mailing Address - Fax:617-740-8070
Practice Address - Street 1:415 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2424
Practice Address - Country:US
Practice Address - Phone:617-287-8000
Practice Address - Fax:617-740-8070
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3083101Medicaid
MAF00515Medicare UPIN
MAJ11673Medicare ID - Type Unspecified