Healthcare Provider Details

I. General information

NPI: 1760314231
Provider Name (Legal Business Name): CONNOR WHITEHEAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KENRICK ST
BRIGHTON MA
02135-3804
US

IV. Provider business mailing address

12 KENRICK ST
BRIGHTON MA
02135-3804
US

V. Phone/Fax

Practice location:
  • Phone: 802-777-9286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPTL89106
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: