Provider Demographics
NPI:1457340515
Name:GANSON-MYSHKIN, NATALIA (MD)
Entity Type:Individual
Prefix:DR
First Name:NATALIA
Middle Name:
Last Name:GANSON-MYSHKIN
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 1:2110 DORCHESTER AVE STE 311
Mailing Address - Street 2:SETON MEDICAL OFFICE BUILDING
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5615
Mailing Address - Country:US
Mailing Address - Phone:617-296-0456
Mailing Address - Fax:
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:617-436-3786
Practice Address - Fax:617-296-5778
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ12678OtherBLUE CROSS/BLUE SHIELD
MA3095347Medicaid
MA64121OtherHARVARD PILGRIM HEALTHCAR
B10065602OtherCIGNA HEALTHCARE
075596OtherTUFTS ASSOCIATED HEALTH P
MA64121OtherHARVARD PILGRIM HEALTHCAR
MAJ12678Medicare ID - Type Unspecified