Provider Demographics
NPI:1962402255
Name:AVERSANO, RENEE (MD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:AVERSANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:521 MOUNT AUBURN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4191
Mailing Address - Country:US
Mailing Address - Phone:617-923-6071
Mailing Address - Fax:617-923-6075
Practice Address - Street 1:10 FORBES RD STE 190
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2622
Practice Address - Country:US
Practice Address - Phone:781-884-6300
Practice Address - Fax:781-884-6305
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA77961207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3113817Medicaid
MA3113817Medicaid
MAF63289Medicare UPIN