Provider Demographics
NPI:1619299138
Name:THORNTON, EAVAN (MB, BCH, BAO,)
Entity Type:Individual
Prefix:DR
First Name:EAVAN
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:MB, BCH, BAO,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 BEACON ST APT 820
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3736
Mailing Address - Country:US
Mailing Address - Phone:617-834-8189
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE.
Practice Address - Street 2:BETH ISRAEL DEACONESS MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-667-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239903390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program