Provider Demographics
NPI:1538256532
Name:ESDALE, AMY BONNER (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:BONNER
Last Name:ESDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:BONNER
Other - Last Name:FITZPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:298 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-4832
Mailing Address - Country:US
Mailing Address - Phone:978-283-2726
Mailing Address - Fax:978-283-0840
Practice Address - Street 1:298 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-4832
Practice Address - Country:US
Practice Address - Phone:978-283-2726
Practice Address - Fax:978-283-0840
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6191045Medicaid
B77141Medicare UPIN
MAJ03952Medicare ID - Type Unspecified