Provider Demographics
NPI:1194914317
Name:DAVID G DOCTOR MD ORTHOPAEDICS AND SPORTS MEDICINE PC
Entity type:Organization
Organization Name:DAVID G DOCTOR MD ORTHOPAEDICS AND SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:DOCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-788-7321
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:299 CAREW STREET
Practice Address - Street 2:SUITE 305
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-788-7321
Practice Address - Fax:413-733-6369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA080082174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM16239OtherBC BS OF MA
MA9774483Medicaid
MA9774483Medicaid