Healthcare Provider Details

I. General information

NPI: 1851381065
Provider Name (Legal Business Name): RICHARD E. GENOVESE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 LAKE ST SUITE 151
GARDNER MA
01440-3889
US

IV. Provider business mailing address

31 LAKE ST STE 151
GARDNER MA
01440-3889
US

V. Phone/Fax

Practice location:
  • Phone: 978-632-5722
  • Fax: 978-630-3240
Mailing address:
  • Phone: 978-632-5722
  • Fax: 978-630-3240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1652
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number1625
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number1625
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: