Healthcare Provider Details

I. General information

NPI: 1164410981
Provider Name (Legal Business Name): GERARD LAWRENCE GAUGHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 DORCHESTER AVE
DORCHESTER CENTER MA
02124-5615
US

IV. Provider business mailing address

2100 DORCHESTER AVE
DORCHESTER CENTER MA
02124-5615
US

V. Phone/Fax

Practice location:
  • Phone: 617-296-4000
  • Fax:
Mailing address:
  • Phone: 617-296-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34480
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: