Provider Demographics
NPI:1255723664
Name:CARDOSO, VITOR
Entity type:Individual
Prefix:
First Name:VITOR
Middle Name:
Last Name:CARDOSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3516
Mailing Address - Country:US
Mailing Address - Phone:617-416-7087
Mailing Address - Fax:
Practice Address - Street 1:47 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3516
Practice Address - Country:US
Practice Address - Phone:617-416-7087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-22
Last Update Date:2015-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2287622363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner