Healthcare Provider Details

I. General information

NPI: 1487622882
Provider Name (Legal Business Name): MERRILL G LITEPLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 BAKER AVE
CONCORD MA
01742-2189
US

IV. Provider business mailing address

290 BAKER AVE
CONCORD MA
01742-2189
US

V. Phone/Fax

Practice location:
  • Phone: 978-369-9023
  • Fax: 978-371-9675
Mailing address:
  • Phone: 978-369-9023
  • Fax: 978-371-9675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35543
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: