Provider Demographics
NPI:1831180660
Name:BROOKLINE VILLAGE DERMATOLOGY PC
Entity type:Organization
Organization Name:BROOKLINE VILLAGE DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL MD
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-277-8332
Mailing Address - Street 1:1 BROOKLINE PL
Mailing Address - Street 2:SUITE 406
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7224
Mailing Address - Country:US
Mailing Address - Phone:617-277-8332
Mailing Address - Fax:617-277-8105
Practice Address - Street 1:1 BROOKLINE PL
Practice Address - Street 2:SUITE 406
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7224
Practice Address - Country:US
Practice Address - Phone:617-277-8332
Practice Address - Fax:617-277-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M20961Medicare ID - Type Unspecified