Healthcare Provider Details

I. General information

NPI: 1255739454
Provider Name (Legal Business Name): DDM RADIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2014
Last Update Date: 12/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 HOLMES RD
LEXINGTON MA
02420-1917
US

IV. Provider business mailing address

18 HOLMES RD
LEXINGTON MA
02420-1917
US

V. Phone/Fax

Practice location:
  • Phone: 781-258-0197
  • Fax: 781-862-5946
Mailing address:
  • Phone: 781-258-0197
  • Fax: 781-862-5946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number51966
License Number StateMA

VIII. Authorized Official

Name: DR. SANFORD SMOOT
Title or Position: PRESIDENT
Credential: MD
Phone: 781-258-0197