Healthcare Provider Details

I. General information

NPI: 1316056815
Provider Name (Legal Business Name): JOHN GRAYDON KIDD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 AVON ST
WAKEFIELD MA
01880-2310
US

IV. Provider business mailing address

33 AVON ST P O BOX 430
WAKEFIELD MA
01880-2310
US

V. Phone/Fax

Practice location:
  • Phone: 781-245-0402
  • Fax:
Mailing address:
  • Phone: 781-245-0402
  • Fax: 781-246-0847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40277
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: