Provider Demographics
NPI:1306823414
Name:KETTYLE, WILLIAM MILLEN (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MILLEN
Last Name:KETTYLE
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:PO BOX 425789
Mailing Address - Street 2:MASS INSTITUTE OF TECHNOLOGY
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-0015
Mailing Address - Country:US
Mailing Address - Phone:617-253-0556
Mailing Address - Fax:617-253-6558
Practice Address - Street 1:77 MASS AVENUE
Practice Address - Street 2:MEDICAL E23
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-253-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA35673207R00000X, 207RE0101X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2041588Medicaid
MAJ17018OtherBCBS MA
MA705990OtherTUFTS
MAJ17018OtherBCBS MA
MA2041588Medicaid