NPIMap

Organization Active NPI

Mystic Valley Mass, PC

  • Dermatology Physician
  • Stoneham, MA
National Provider Identifier
1184377343
Registry record updated Jan 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
MYSTIC VALLEY MASS, PC
Practice address
92 Montvale Ave Ste 3000
Stoneham, MA 02180-3658
Phone
(781) 438-6350
NPI assigned
Jan 28, 2022
Organization subpart
Yes
Parent organization
MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 28, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel Goos
Title
Owner
Phone
(783) 717-0109

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

92 Montvale Ave Ste 3000
Stoneham, MA 02180-3658

Mailing address

526 Main St Ste 302
Acton, MA 01720-3301
Phone (978) 371-7010

National Provider Directory

National Provider Directory
Tax ID family
Advanced Derm Mass LLC2 organizations share this tax ID, including this one
Part of
Donald J Grande MD PC

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1643328000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643328000000",
    "number": "1184377343",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "526 MAIN ST STE 302",
            "city": "ACTON",
            "state": "MA",
            "postal_code": "017203301",
            "telephone_number": "978-371-7010"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "92 MONTVALE AVE STE 3000",
            "city": "STONEHAM",
            "state": "MA",
            "postal_code": "021803658",
            "telephone_number": "781-438-6350"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MYSTIC VALLEY MASS, PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.",
        "enumeration_date": "2022-01-28",
        "last_updated": "2022-01-28",
        "certification_date": "2022-01-28",
        "status": "A",
        "authorized_official_last_name": "GOOS",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "783-717-0109"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Stoneham, MA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.