Healthcare Provider Details

I. General information

NPI: 1356435366
Provider Name (Legal Business Name): JOSEPH WILLIAM DESIATO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/09/2007
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: 978-475-3279
Mailing address:
  • Phone: 978-475-0300
  • Fax: 978-475-3279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: