Basic Information
| Provider Information | |||||||||
| NPI: | 1598749939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANTON | ||||||||
| FirstName: | GARY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9135 | ||||||||
| Address2: | ATTN SHARON SILVA | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
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| Practice Location | |||||||||
| Address1: | JOHN CUMMINGS BLDG, EMMERSON HOSPITAL | ||||||||
| Address2: | STE 500 | ||||||||
| City: | CONCORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083718935 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 44341 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 6165109 | 05 | MA | MEDICAID | 703177 | 01 | MA | TUFTS HEALTH PLAN | OTHER | J02257 | 01 | MA | BCBS | OTHER |