Provider Demographics
NPI:1215987763
Name:GANSON, JORGE (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:GANSON
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 1:193 GAY ST
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2514
Mailing Address - Country:US
Mailing Address - Phone:508-427-3106
Mailing Address - Fax:508-427-2538
Practice Address - Street 1:235 N PEARL ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1794
Practice Address - Country:US
Practice Address - Phone:508-427-3106
Practice Address - Fax:508-427-2538
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0318022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2025272Medicaid
MA2025272Medicaid
MAC20181Medicare ID - Type Unspecified