1194811505 NPI number — DR. DONALD ROY GEDAROVICH MD

Table of content: DR. DONALD ROY GEDAROVICH MD (NPI 1194811505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194811505 NPI number — DR. DONALD ROY GEDAROVICH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEDAROVICH
Provider First Name:
DONALD
Provider Middle Name:
ROY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194811505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 LIBERTY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFILED
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-359-8115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1426 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
WALPOLE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-660-8874
Provider Business Practice Location Address Fax Number:
805-660-8651
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  48901 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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