Provider Demographics
NPI:1285959676
Name:MACIP RODRIGUEZ, PERLA MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:PERLA
Middle Name:MICHELLE
Last Name:MACIP RODRIGUEZ
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 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:
Practice Address - Street 1:801 MASSACHUSETTS AVENUE
Practice Address - Street 2:CROSSTOWN 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2605
Practice Address - Country:US
Practice Address - Phone:617-414-7399
Practice Address - Fax:617-414-4676
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254670207RG0300X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110102924AMedicaid