MEDICARE: DDM RADIOLOGY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	51966	MA

General Provider Information

NPI Number	:	1255739454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DDM RADIOLOGY PC

Provider Business Mailing Address
First Line	:	18 HOLMES RD
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420-1917
Country	:	US
Telephone Number	:	781-258-0197
Fax Number	:	781-862-5946

Provider Business Practice Location Address
First Line	:	18 HOLMES RD
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420-1917
Country	:	US
Telephone Number	:	781-258-0197
Fax Number	:	781-862-5946

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SANFORD SMOOT
Credential	:	MD
Telephone Number	:	781-258-0197

Provider Enumeration Date	:	12/21/2014
Last Update Date	:	12/21/2014

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