Healthcare Provider Details

I. General information

NPI: 1356839518
Provider Name (Legal Business Name): LEWIS RICHARD GERGOUDIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1153 CENTRE ST
JAMAICA PLAIN MA
02130-3446
US

IV. Provider business mailing address

399 REVOLUTION DR
SOMERVILLE MA
02145-1484
US

V. Phone/Fax

Practice location:
  • Phone: 617-983-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1025841
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: