Provider Demographics
NPI:1215962162
Name:TUNICK, MITCHELL OWEN (MD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:OWEN
Last Name:TUNICK
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 1:27 MAY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3032
Mailing Address - Country:US
Mailing Address - Phone:617-524-9524
Mailing Address - Fax:617-522-6366
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:SUITE 31
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-522-3100
Practice Address - Fax:617-522-6366
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55132208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3024377Medicaid
MAJ08070Medicare ID - Type Unspecified
MA3024377Medicaid