Healthcare Provider Details

I. General information

NPI: 1023403938
Provider Name (Legal Business Name): JOHN ROBINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-3850
  • Fax:
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD202546
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberT291789
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: