Healthcare Provider Details

I. General information

NPI: 1366731150
Provider Name (Legal Business Name): JOHN VALENTINE CHISHOLM III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 NEPONSET ST
WORCESTER MA
01606
US

IV. Provider business mailing address

5 NEPONSET ST
WORCESTER MA
01606-2714
US

V. Phone/Fax

Practice location:
  • Phone: 508-595-2300
  • Fax: 508-853-5226
Mailing address:
  • Phone: 508-595-2300
  • Fax: 508-853-5226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-0012873
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number277524
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: