Provider Demographics
NPI:1609190685
Name:MICHELSON, CATHERINE DISTLER (MD)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:DISTLER
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:L
Other - Last Name:DISTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
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 1:850 HARRISON AVE
Practice Address - Street 2:YACC 6
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-5946
Practice Address - Fax:617-414-4541
Is Sole Proprietor?:No
Enumeration Date:2010-03-20
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254327208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095818AMedicaid
MA003265201Medicare PIN