Healthcare Provider Details

I. General information

NPI: 1992789911
Provider Name (Legal Business Name): JOSEPH AUDETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-8817
  • Fax: 617-421-2226
Mailing address:
  • Phone: 617-421-8817
  • Fax: 617-421-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number81464
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number81464
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: