Provider Demographics
NPI:1972505402
Name:KAUTZKY, MIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:
Last Name:KAUTZKY
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 1:15 PARKMAN ST
Mailing Address - Street 2:SUITE 645, WACC
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-724-0646
Mailing Address - Fax:617-724-0656
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:SUITE 645, WACC
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-724-0646
Practice Address - Fax:617-724-0656
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-070882-L207R00000X
MA242083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H20554Medicare UPIN
PAH20554Medicare UPIN