Provider Demographics
NPI:1922493394
Name:BUELT, ELIZA (MD)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:BUELT
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 1:20 VINING ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6115
Mailing Address - Country:US
Mailing Address - Phone:617-626-9300
Mailing Address - Fax:
Practice Address - Street 1:20 VINING ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6115
Practice Address - Country:US
Practice Address - Phone:617-626-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2825522084P0800X
390200000X
VA01012654422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program