Provider Demographics
NPI:1790363943
Name:MANELIN, ETHAN (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:MANELIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ETHAN
Other - Middle Name:COUGHLIN
Other - Last Name:BALGLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-6106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 MASSACHUSETTS AVE
Practice Address - Street 2:CROSSTOWN 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-7399
Practice Address - Fax:617-414-9201
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1019038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine