Provider Demographics
NPI:1295745495
Name:PRO-RISQUEZ, MARIA ALEJANDRA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ALEJANDRA
Last Name:PRO-RISQUEZ
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 1:11 NEVINS ST
Mailing Address - Street 2:#505
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3514
Mailing Address - Country:US
Mailing Address - Phone:617-782-9210
Mailing Address - Fax:617-782-8565
Practice Address - Street 1:11 NEVINS ST
Practice Address - Street 2:#505
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3514
Practice Address - Country:US
Practice Address - Phone:617-782-9210
Practice Address - Fax:617-782-8565
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205824207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0151491Medicaid
MAH49185Medicare UPIN
MA0151491Medicaid