Provider Demographics
NPI:1386642031
Name:LOUIS G. DUSSEAULT, JR., MD, PC
Entity Type:Organization
Organization Name:LOUIS G. DUSSEAULT, JR., MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DUSSEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:781-762-8427
Mailing Address - Street 1:825 WASHINGTON ST
Mailing Address - Street 2:SUITE 370
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3441
Mailing Address - Country:US
Mailing Address - Phone:781-762-8427
Mailing Address - Fax:781-762-2011
Practice Address - Street 1:825 WASHINGTON ST
Practice Address - Street 2:SUITE 370
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3441
Practice Address - Country:US
Practice Address - Phone:781-762-8427
Practice Address - Fax:781-762-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56357207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALO M21578Medicare ID - Type Unspecified