Provider Demographics
NPI:1841286887
Name:MISCHOULON, DAVID (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MISCHOULON
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 1:40 VARNUM ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-8713
Mailing Address - Country:US
Mailing Address - Phone:781-641-4458
Mailing Address - Fax:617-724-3028
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL, WAC-812
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-724-5198
Practice Address - Fax:617-724-3028
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1525392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA152539OtherTUFTS
MA3176991Medicaid
MAJ18671OtherBCBS
MA152539OtherTUFTS
MA3176991Medicaid