Provider Demographics
NPI:1447268222
Name:VANELLI, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:VANELLI
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:PO BOX 260
Mailing Address - Street 2:MOAK ASSOCIATES
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-0260
Mailing Address - Country:US
Mailing Address - Phone:508-898-8650
Mailing Address - Fax:508-870-9793
Practice Address - Street 1:21 LONGMEADOW RD
Practice Address - Street 2:MOAK ASSOCIATES
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-2419
Practice Address - Country:US
Practice Address - Phone:508-898-8650
Practice Address - Fax:508-870-9793
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA600762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15-00999OtherEVERCARE
MAJ09205OtherBLUE SHIELD
MA3056244Medicaid
MA776748OtherTUFTS
MAJ09205OtherBLUE SHIELD
MAE29239Medicare UPIN
MA3056244Medicaid