Provider Demographics
NPI:1639158926
Name:PROTIVA, JANET S (MD)
Entity Type:Individual
Prefix:MS
First Name:JANET
Middle Name:S
Last Name:PROTIVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4199 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131
Mailing Address - Country:US
Mailing Address - Phone:617-323-4440
Mailing Address - Fax:617-323-7870
Practice Address - Street 1:4199 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131
Practice Address - Country:US
Practice Address - Phone:617-323-4440
Practice Address - Fax:617-323-7870
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81601208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
202221BMCOtherHARVARD PILGRIM
MA3206564Medicaid
J22092OtherBC
A30759Medicare ID - Type Unspecified
MA3206564Medicaid