Provider Demographics
NPI:1508833641
Name:TROTTA, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:TROTTA
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 1:200 CORPORATE PL
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-3840
Mailing Address - Country:US
Mailing Address - Phone:978-535-1344
Mailing Address - Fax:781-255-0594
Practice Address - Street 1:200 CORPORATE PL
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-3840
Practice Address - Country:US
Practice Address - Phone:978-535-1344
Practice Address - Fax:781-255-0594
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3048250Medicaid
MA3048250Medicaid
MAD33548Medicare UPIN