Provider Demographics
NPI:1275528192
Name:GORSON, KENNETH C (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:GORSON
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 1:110 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-3527
Mailing Address - Country:US
Mailing Address - Phone:781-591-8300
Mailing Address - Fax:781-591-8320
Practice Address - Street 1:110 CEDAR ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-3527
Practice Address - Country:US
Practice Address - Phone:781-591-8300
Practice Address - Fax:781-591-8320
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA711072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3095894Medicaid
MA3095894Medicaid
MAJ12139Medicare ID - Type Unspecified