Healthcare Provider Details

I. General information

NPI: 1306823414
Provider Name (Legal Business Name): WILLIAM MILLEN KETTYLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MASS AVENUE MEDICAL E23
CAMBRIDGE MA
02139
US

IV. Provider business mailing address

PO BOX 425789 MASS INSTITUTE OF TECHNOLOGY
CAMBRIDGE MA
02142-0015
US

V. Phone/Fax

Practice location:
  • Phone: 617-253-4487
  • Fax:
Mailing address:
  • Phone: 617-253-0556
  • Fax: 617-253-6558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35673
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number35673
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number35673
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: