Provider Demographics
NPI:1528234507
Name:AMIRTHARAJ, DOMINIC G (MD)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:G
Last Name:AMIRTHARAJ
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 1:55 FOGG RD
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-2432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 E CONCORD ST
Practice Address - Street 2:EVANS 124
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2307
Practice Address - Country:US
Practice Address - Phone:617-638-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine