Provider Demographics
NPI:1558352450
Name:GERVAIS, DEBRA A (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:A
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-8386
Mailing Address - Fax:617-726-4891
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:PLL 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-8396
Practice Address - Fax:617-726-4891
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA813552085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3139832Medicaid
MA750293OtherTUFTS HEALTH PLAN
MAJ31339OtherBCBS MA
MA3139832Medicaid
MAJ31339OtherBCBS MA