Healthcare Provider Details

I. General information

NPI: 1023422607
Provider Name (Legal Business Name): KEVIN RAYMOND GENDREAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LIBERTY ST
BROCKTON MA
02301-5674
US

IV. Provider business mailing address

110 LIBERTY ST STE 180
BROCKTON MA
02301-5674
US

V. Phone/Fax

Practice location:
  • Phone: 508-894-0400
  • Fax: 508-565-0097
Mailing address:
  • Phone: 508-894-0766
  • Fax: 508-565-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD17833
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number270162
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number270162
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: