Provider Demographics
NPI:1265545917
Name:MASSICOTT, PETER J (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MASSICOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:75 MOUNT AUBURN ST
Mailing Address - Street 2:HARVARD UNIVERSITY HEALTH SERVICES
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4960
Mailing Address - Country:US
Mailing Address - Phone:617-432-1370
Mailing Address - Fax:617-432-7120
Practice Address - Street 1:275 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5704
Practice Address - Country:US
Practice Address - Phone:617-432-1370
Practice Address - Fax:617-432-7120
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA76162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA076162OtherTUFTS HEALTH PLAN
MAJ30276OtherBC/BS OF MA
MAF21865Medicare UPIN
MAJ30276OtherBC/BS OF MA