Provider Demographics
NPI:1306814272
Name:BRECKWOLDT, WILLIAM L III (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:BRECKWOLDT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 MAIN ST
Mailing Address - Street 2:SUITE G2A
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1961
Mailing Address - Country:US
Mailing Address - Phone:781-729-2020
Mailing Address - Fax:781-729-6846
Practice Address - Street 1:955 MAIN STREET
Practice Address - Street 2:SUITE G2A
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1961
Practice Address - Country:US
Practice Address - Phone:781-729-2020
Practice Address - Fax:781-729-6846
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA70797174400000X, 208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3053318Medicaid
MAD99814Medicare UPIN
MAJ08434Medicare ID - Type Unspecified