Provider Demographics
NPI:1871575548
Name:MOGAVERO, NICOLA (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:
Last Name:MOGAVERO
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 1:792 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2710
Mailing Address - Country:US
Mailing Address - Phone:781-665-9066
Mailing Address - Fax:781-662-9758
Practice Address - Street 1:792 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2710
Practice Address - Country:US
Practice Address - Phone:781-665-9066
Practice Address - Fax:781-662-9758
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81784207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3176886Medicaid
MAJ18677OtherBCBS
MA66877OtherHPHC
MA778258OtherTUFTS/SECURE HORIZONS
MAA23700Medicare ID - Type Unspecified
MA3176886Medicaid