Provider Demographics
NPI:1689867053
Name:ITURRINO MOREDA, JOHANNA C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:C
Last Name:ITURRINO MOREDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHANNA
Other - Middle Name:C
Other - Last Name:ITURRINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-2137
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-2137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52247207RG0100X
PR17220207R00000X
MA266575207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
WIENROLLEDMedicaid
MNENROLLEDMedicaid
MNP01195948OtherRAILROAD MEDICARE
MNENROLLEDMedicaid