Healthcare Provider Details

I. General information

NPI: 1780613935
Provider Name (Legal Business Name): JEFFREY S GORODETSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MILL ST
LEOMINSTER MA
01453-3289
US

IV. Provider business mailing address

630 PLANTATION ST WOT 12TH FL
WORCESTER MA
01605-2038
US

V. Phone/Fax

Practice location:
  • Phone: 978-466-3212
  • Fax: 978-534-3581
Mailing address:
  • Phone: 508-368-5532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME0053894
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number262412
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: