Provider Demographics
NPI:1932151065
Name:LAGOS, ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:LAGOS
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 1:72 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-4649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-4649
Practice Address - Country:US
Practice Address - Phone:781-431-1106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-08-14
Deactivation Date:2017-08-11
Deactivation Code:
Reactivation Date:2019-08-14
Provider Licenses
StateLicense IDTaxonomies
MA203156207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ40159OtherBCBS INDEMNITY
MAI61460Medicare UPIN
MA2124831Medicaid
MALA-A40354Medicare PIN
MA7437809OtherAETNA