Healthcare Provider Details

I. General information

NPI: 1356390215
Provider Name (Legal Business Name): RICHARD JOHN KERBEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 MOUNT AUBURN ST
WATERTOWN MA
02472-4122
US

IV. Provider business mailing address

548 MOUNT AUBURN ST
WATERTOWN MA
02472-4122
US

V. Phone/Fax

Practice location:
  • Phone: 617-923-1040
  • Fax:
Mailing address:
  • Phone: 617-923-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number45421
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: