Provider Demographics
NPI:1194811505
Name:GEDAROVICH, DONALD ROY (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ROY
Last Name:GEDAROVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LIBERTY ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDFILED
Mailing Address - State:MA
Mailing Address - Zip Code:02052
Mailing Address - Country:US
Mailing Address - Phone:508-359-8115
Mailing Address - Fax:
Practice Address - Street 1:1426 MAIN STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081
Practice Address - Country:US
Practice Address - Phone:508-660-8874
Practice Address - Fax:805-660-8651
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48901207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA40725Medicare UPIN
MAC09016Medicare ID - Type Unspecified