Healthcare Provider Details

I. General information

NPI: 1972590487
Provider Name (Legal Business Name): RODEGELIO C ESTRADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 SOUTH ST STE 4
WARE MA
01082-1660
US

IV. Provider business mailing address

83 SOUTH ST STE 4
WARE MA
01082-1660
US

V. Phone/Fax

Practice location:
  • Phone: 413-967-5588
  • Fax: 413-967-3166
Mailing address:
  • Phone: 413-967-5588
  • Fax: 413-967-3166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number44191
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: