Provider Demographics
NPI:1891255865
Name:BENSSON-RAVUNNIARATH, MARA (MD)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:BENSSON-RAVUNNIARATH
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 1:50 STANIFORD ST FL 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2506
Mailing Address - Country:US
Mailing Address - Phone:617-724-6610
Mailing Address - Fax:
Practice Address - Street 1:50 STANIFORD ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2517
Practice Address - Country:US
Practice Address - Phone:617-724-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA291312207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine