Provider Demographics
NPI:1396823910
Name:HUMPHREYS, ELIZABETH HARRINGTON (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HARRINGTON
Last Name:HUMPHREYS
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 1:25 WALNUT ST
Mailing Address - Street 2:STE 102
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:781-489-5546
Mailing Address - Fax:781-489-5769
Practice Address - Street 1:25 WALNUT ST
Practice Address - Street 2:STE 102
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-489-5546
Practice Address - Fax:781-489-5769
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83403208000000X
MA242783208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110085365Medicaid
I10070Medicare UPIN
MA110085365Medicaid