Provider Demographics
NPI:1154391837
Name:STAVITSKY, MILANA (MD)
Entity type:Individual
Prefix:
First Name:MILANA
Middle Name:
Last Name:STAVITSKY
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 1:422 WORCESTER ST
Mailing Address - Street 2:SUITE 103-105
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:781-235-9737
Mailing Address - Fax:781-235-9738
Practice Address - Street 1:422 WORCESTER ST
Practice Address - Street 2:SUITE 103-105
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-235-9737
Practice Address - Fax:781-235-9738
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78887208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19207OtherBCBS
MA20-1792042OtherTAX ID
C31654OtherBCBS
200995OtherHARVARD PILGRIM
MA3149811Medicaid
MA402449OtherTUFTS
MA3149811Medicaid
MAA21980Medicare ID - Type Unspecified