Provider Demographics
NPI:1588628853
Name:TEDESCO, BRIAN D (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:TEDESCO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2190
Mailing Address - Street 2:
Mailing Address - City:WEST PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-7190
Mailing Address - Country:US
Mailing Address - Phone:781-231-7026
Mailing Address - Fax:
Practice Address - Street 1:53 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1448
Practice Address - Country:US
Practice Address - Phone:617-629-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2199213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0364011Medicaid
MA0032245OtherNEIGHBORHOOD HEALTH
11318840OtherCAQH
202648900OtherDEPT. OF LABOR-WC
MA972127OtherNETWORK HEALTH
MA2180343OtherHEALTHCARE VALUE
MA2180343OtherFIRST HEALTH-MA LABORERS
MA334226OtherHARVARD PILGRIM HEALTH
MA746579OtherCIGNA
MA002199OtherTUFTSHEALTH CARE
MA96048OtherFALLON
MADB4378OtherRAILROAD MEDICARE
MAY71104OtherBLUE CROSS/BLUE SHIELD
MA2180343OtherHEALTHCARE VALUE
Y75126Medicare ID - Type Unspecified
202648900OtherDEPT. OF LABOR-WC