=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497778450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D & G ASSOCIATES WALTHAM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1440 MAIN ST
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-1623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-891-9300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 WINTER ST
-----------------------------------------------------
City | HOLBROOK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02343-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-767-3486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | DR. CONRAD GOLASKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-767-3486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 110296
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------