Provider Demographics
NPI:1750015640
Name:LATZER, ITAY TOKATLY (MD)
Entity type:Individual
Prefix:DR
First Name:ITAY TOKATLY
Middle Name:
Last Name:LATZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ITAY
Other - Middle Name:
Other - Last Name:TOKATLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 ALTON CT APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-6728
Mailing Address - Country:US
Mailing Address - Phone:781-531-0481
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-735-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA292352282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMTN961241126OtherBLUE CROSS BLUE SHIELD (BCBS)