Healthcare Provider Details

I. General information

NPI: 1316069149
Provider Name (Legal Business Name): JOSEPH W. DESIATO, M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 N MAIN ST
ANDOVER MA
01810-2687
US

IV. Provider business mailing address

349 N MAIN ST
ANDOVER MA
01810-2687
US

V. Phone/Fax

Practice location:
  • Phone: 978-475-0300
  • Fax:
Mailing address:
  • Phone: 978-475-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number55584
License Number StateMA

VIII. Authorized Official

Name: DR. JOSEPH W DESIATO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 978-475-0300