Provider Demographics
NPI:1205806908
Name:AVERSA, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:AVERSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2964
Mailing Address - Country:US
Mailing Address - Phone:508-791-4300
Mailing Address - Fax:508-756-8777
Practice Address - Street 1:116 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2964
Practice Address - Country:US
Practice Address - Phone:508-791-4300
Practice Address - Fax:508-756-8777
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53840207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3005461Medicaid
MAJ05195Medicare PIN
MAA58258Medicare UPIN