Provider Demographics
NPI:1750592762
Name:DANA K. FUGELSO, M.D.
Entity type:Organization
Organization Name:DANA K. FUGELSO, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:FUGELSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-731-8334
Mailing Address - Street 1:1101 BEACON ST
Mailing Address - Street 2:SUITE 1 WEST
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5587
Mailing Address - Country:US
Mailing Address - Phone:781-731-8334
Mailing Address - Fax:781-731-8556
Practice Address - Street 1:1101 BEACON ST
Practice Address - Street 2:SUITE 1 WEST
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5587
Practice Address - Country:US
Practice Address - Phone:781-731-8334
Practice Address - Fax:781-731-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74545174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3133699Medicaid
MAJ31041Medicare ID - Type Unspecified
MAD28587Medicare UPIN