Basic Information
| Provider Information | |||||||||
| NPI: | 1043553969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARDESTANI | ||||||||
| FirstName: | ALI | ||||||||
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| Credential: | MD, MSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2014 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024621699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172436000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 282820 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 282820 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.