Provider Demographics
NPI:1629095070
Name:TLUMACKI, MARK (OP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TLUMACKI
Suffix:
Gender:M
Credentials:OP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DALTON RD
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-2416
Mailing Address - Country:US
Mailing Address - Phone:508-429-7758
Mailing Address - Fax:508-429-7614
Practice Address - Street 1:45 DALTON RD
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746-2416
Practice Address - Country:US
Practice Address - Phone:508-429-7758
Practice Address - Fax:508-429-7614
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA336654OtherBCBS OF MA
MA9786473Medicaid
MA9786473Medicaid