Provider Demographics
NPI:1851500300
Name:IBEZIAKO, PATRICIA I (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:I
Last Name:IBEZIAKO
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 1:104 QUEENSBERRY ST
Mailing Address - Street 2:APT B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4714
Mailing Address - Country:US
Mailing Address - Phone:617-670-3528
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6680
Practice Address - Fax:617-730-0319
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2240052084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry