Healthcare Provider Details

I. General information

NPI: 1083695126
Provider Name (Legal Business Name): JOHN F. MULQUEEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 LAWRENCE ST
GARDNER MA
01440-2364
US

IV. Provider business mailing address

190 LAWRENCE ST
GARDNER MA
01440-2364
US

V. Phone/Fax

Practice location:
  • Phone: 978-630-2306
  • Fax: 978-630-3182
Mailing address:
  • Phone: 978-630-2306
  • Fax: 978-630-3182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70395
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3045501
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: