Provider Demographics
NPI:1811459837
Name:HONSHIDELER, KELSEY IDINA (MD)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:IDINA
Last Name:HONSHIDELER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELSEY
Other - Middle Name:IDINA
Other - Last Name:SHIDELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:820 HARRISON AVE.
Mailing Address - Street 2:FGH BUILDING, 4TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 HARRISON AVE.
Practice Address - Street 2:FGH BUILDING, 4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-6604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60962155208600000X
MA289565390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery