Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 32219 | MA |
NPI | 1043367097 |
---|---|
Provider Name | John A Libertino |
First Address | Burlington, MA 01805-0001 |
Second Address | Burlington, MA 01805-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 18/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6166768 | (05) | MA |
A65937 | (02) | MA |