Provider Demographics
NPI:1346396561
Name:MEDEIROS, MARY A (MD, MPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:ABASTILLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:835 W CENTRAL ST STE 4
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-3189
Mailing Address - Country:US
Mailing Address - Phone:774-318-4205
Mailing Address - Fax:774-512-0093
Practice Address - Street 1:835 W CENTRAL ST STE 4
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-3189
Practice Address - Country:US
Practice Address - Phone:774-318-4205
Practice Address - Fax:774-512-0093
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232763207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2144387Medicaid
MA000419001Medicare PIN