Provider Demographics
NPI:1871919506
Name:O'ROURKE, DECLAN JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:DECLAN
Middle Name:JOHN
Last Name:O'ROURKE
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 1:300 LONGWOOD AVE
Mailing Address - Street 2:FEGAN 9
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-620-5218
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:FEGAN 9
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-620-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA256277390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program