Provider Demographics
NPI:1104829423
Name:OLDERSHAW, JOHN HALLOCK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HALLOCK
Last Name:OLDERSHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 CRANBERRY HIGHWAY
Mailing Address - Street 2:ATTN: NANCI KARDOS-CARLL/PROVIDER RELATIONS DEPT.
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-1046
Mailing Address - Country:US
Mailing Address - Phone:800-841-5200
Mailing Address - Fax:508-273-1241
Practice Address - Street 1:85 HERRICK ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1776
Practice Address - Country:US
Practice Address - Phone:978-922-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA727832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3070786Medicaid