Provider Demographics
NPI:1710390851
Name:PROM DE ILLANES, MARIA C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:C
Last Name:PROM DE ILLANES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:C
Other - Last Name:PROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2693712084P0015X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110106417AMedicaid