Provider Demographics
NPI:1700049269
Name:NA, XI (MD, PHD)
Entity Type:Individual
Prefix:
First Name:XI
Middle Name:
Last Name:NA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WOODLAND ROAD
Mailing Address - Street 2:SUITE #312
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:78166-4862
Mailing Address - Country:US
Mailing Address - Phone:781-662-0604
Mailing Address - Fax:781-665-4162
Practice Address - Street 1:3 WOODLAND ROAD
Practice Address - Street 2:SUITE #312
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180
Practice Address - Country:US
Practice Address - Phone:781-662-0604
Practice Address - Fax:781-665-4162
Is Sole Proprietor?:No
Enumeration Date:2008-07-04
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA253157207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program