Provider Demographics
NPI:1619956810
Name:KAMVERIS, SOPHIA C (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:C
Last Name:KAMVERIS
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 MASSACHUSETTS AVE
Mailing Address - Street 2:UNIT 460
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3805
Mailing Address - Country:US
Mailing Address - Phone:781-274-0268
Mailing Address - Fax:781-274-0269
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 105
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:617-515-8984
Practice Address - Fax:781-274-0269
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1137133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA39464OtherHARVARD PILGIM HEALTH CAR
MALD0121OtherBLUE CROSS BLUE SHIELD
MA1703129OtherCIGNA
MA470011OtherTUFT'S TOTAL HEALTH PLAN
CT7541546OtherAETNA
MAP86807Medicare UPIN
MA470011OtherTUFT'S TOTAL HEALTH PLAN