Provider Demographics
NPI:1942289194
Name:O'SULLIVAN, RENEE B (MD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:B
Last Name:O'SULLIVAN
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 1:14 DENTON RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-6405
Mailing Address - Country:US
Mailing Address - Phone:781-235-1007
Mailing Address - Fax:781-235-0006
Practice Address - Street 1:14 DENTON RD
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-6405
Practice Address - Country:US
Practice Address - Phone:781-235-1007
Practice Address - Fax:781-235-0006
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-15
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25715208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA53890Medicare UPIN