Provider Demographics
NPI:1609859057
Name:FYNN-THOMPSON, NICOLETTA A (MD)
Entity Type:Individual
Prefix:
First Name:NICOLETTA
Middle Name:A
Last Name:FYNN-THOMPSON
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:50 STANIFORD ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2517
Mailing Address - Country:US
Mailing Address - Phone:617-367-4800
Mailing Address - Fax:617-723-7028
Practice Address - Street 1:50 STANIFORD ST
Practice Address - Street 2:SUITE 600
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2517
Practice Address - Country:US
Practice Address - Phone:617-367-4800
Practice Address - Fax:617-723-7028
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA216971207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA471664OtherTUFTS HEALTH PLAN
MAJ26384OtherBCBS MA
MA2078341Medicaid
MA110038924AMedicaid
H87046Medicare UPIN
MAJ26384OtherBCBS MA
MA471664OtherTUFTS HEALTH PLAN