Provider Demographics
NPI:1982695284
Name:PACHECO, MANUEL N (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:N
Last Name:PACHECO
Suffix:
Gender:M
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:PO BOX 440304
Mailing Address - Street 2:
Mailing Address - City:WEST SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-0027
Mailing Address - Country:US
Mailing Address - Phone:617-872-6522
Mailing Address - Fax:617-876-9998
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:TUFTS MEDICAL CENTER BOX 1007
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-872-6522
Practice Address - Fax:617-876-9998
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2166802084P0800X, 2084P0015X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2106655Medicaid
MA2106655Medicaid
A38623Medicare ID - Type Unspecified