Provider Demographics
NPI:1821071168
Name:MIRKATULI, ATHAR (MD)
Entity Type:Individual
Prefix:
First Name:ATHAR
Middle Name:
Last Name:MIRKATULI
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 1:85 E CONCORD ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2335
Mailing Address - Country:US
Mailing Address - Phone:617-414-5196
Mailing Address - Fax:617-414-7300
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4072
Practice Address - Country:US
Practice Address - Phone:617-414-4893
Practice Address - Fax:617-414-7212
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57817207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3051145Medicaid
MA3051145Medicaid
MAE19753Medicare UPIN