Provider Demographics
NPI:1568557775
Name:NORONHA, ANSU MAMMEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANSU
Middle Name:MAMMEN
Last Name:NORONHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANSU
Other - Middle Name:A
Other - Last Name:MAMMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:720 HARRISON AVE # DOB503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVENUE
Practice Address - Street 2:MOAKLEY, 2ND FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6525
Practice Address - Fax:617-638-7448
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226565207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110083854AMedicaid
MA01356701Medicare PIN