Provider Demographics
NPI:1598743742
Name:GHOSH ROY, AMITABHA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMITABHA
Middle Name:
Last Name:GHOSH ROY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-3875
Mailing Address - Country:US
Mailing Address - Phone:617-696-1510
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3881
Practice Address - Country:US
Practice Address - Phone:617-696-1510
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32910208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0131431Medicaid
MAB75677Medicare UPIN
MA0131431Medicaid