Provider Demographics
NPI:1770592941
Name:LIDOV, HART GW (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:HART
Middle Name:GW
Last Name:LIDOV
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WHITTIER PL
Mailing Address - Street 2:UNIT #7G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-1443
Mailing Address - Country:US
Mailing Address - Phone:617-523-3458
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:617-355-7431
Practice Address - Fax:617-730-0207
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56280207ZN0500X, 207ZP0101X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Not Answered207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Not Answered2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B75114Medicare UPIN