Provider Demographics
NPI:1114118098
Name:GLENN A DOBECKI MD INC
Entity Type:Organization
Organization Name:GLENN A DOBECKI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:DOBECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-335-5791
Mailing Address - Street 1:571 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1843
Mailing Address - Country:US
Mailing Address - Phone:781-335-5791
Mailing Address - Fax:781-331-3242
Practice Address - Street 1:571 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1843
Practice Address - Country:US
Practice Address - Phone:781-335-5781
Practice Address - Fax:781-331-3242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30427207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M12022Medicare Oscar/Certification
A53946Medicare UPIN