Provider Demographics
NPI:1801984349
Name:DANTZLER, ANNE ELLSWORTH (MD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:ELLSWORTH
Last Name:DANTZLER
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 1:250 HAMMOND POND PKWY
Mailing Address - Street 2:410N
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-1545
Mailing Address - Country:US
Mailing Address - Phone:617-699-7642
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST, BLDG 2, 3RD FLOOR, WARD 2-3-B OR A310
Practice Address - Street 2:VA BOSTON HEALTHCARE SYSTEM, BROCKTON DIVISION
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-1408
Practice Address - Fax:774-826-3217
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA445392084F0202X, 2084P0015X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ16409OtherBLUE CROSS/BLUE SHIELD
MAG22312Medicare UPIN
MAJ16409OtherBLUE CROSS/BLUE SHIELD