Provider Demographics
NPI:1063576296
Name:NEYSHTADT, ALLA I (MD)
Entity type:Individual
Prefix:
First Name:ALLA
Middle Name:I
Last Name:NEYSHTADT
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 1:2000 WASHINGTON ST
Mailing Address - Street 2:BLUE BUILDING, SUITE 420
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1650
Mailing Address - Country:US
Mailing Address - Phone:617-630-9823
Mailing Address - Fax:
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:BLUE BUILDING, SUITE 420
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1650
Practice Address - Country:US
Practice Address - Phone:617-630-9823
Practice Address - Fax:617-630-4481
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA150852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3153380Medicaid
MAA21283Medicare PIN