Provider Demographics
NPI:1164479705
Name:DIEDWARDO, CHRISTINE ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:ANNE
Last Name:DIEDWARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-5100
Mailing Address - Fax:781-744-5215
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-5100
Practice Address - Fax:781-744-5215
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204888208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110004228AMedicaid
MA0151246Medicaid
MAH23209Medicare UPIN
MAA33140Medicare PIN