Provider Demographics
NPI:1619961968
Name:DRYJA, THADDEUS P (MD)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:P
Last Name:DRYJA
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:PO BOX 8010
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-0916
Mailing Address - Country:US
Mailing Address - Phone:617-573-4458
Mailing Address - Fax:617-573-4037
Practice Address - Street 1:243 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3002
Practice Address - Country:US
Practice Address - Phone:617-573-3319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41891207W00000X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0148296Medicaid
MAB73592Medicare UPIN
MAC20263Medicare ID - Type Unspecified