Provider Demographics
NPI:1972657021
Name:FOTI, MARY ELLEN GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:GRACE
Last Name:FOTI
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 1:320 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4339
Mailing Address - Country:US
Mailing Address - Phone:617-327-7595
Mailing Address - Fax:
Practice Address - Street 1:25 STANIFORD ST
Practice Address - Street 2:CLINICAL AND PROFESSIONAL SERVICES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2503
Practice Address - Country:US
Practice Address - Phone:617-626-8116
Practice Address - Fax:617-626-8225
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA541632084F0202X, 2084P0800X
FLME 602832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ05992OtherBCBS
MAB95316Medicare UPIN