Basic Information
| Provider Information | |||||||||
| NPI: | 1275515694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CZERNIACH | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022410001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 67 BELMONT ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083346406 | ||||||||
| FaxNumber: | 5083346515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2005 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 209844 | MA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 110004420A | 05 | MA | MEDICAID |