Provider Demographics
NPI:1598721524
Name:GULDEMOND, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:GULDEMOND
Suffix:
Gender:M
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:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4260
Mailing Address - Country:US
Mailing Address - Phone:781-756-7273
Mailing Address - Fax:781-756-7274
Practice Address - Street 1:500 SALEM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-1200
Practice Address - Country:US
Practice Address - Phone:978-988-6000
Practice Address - Fax:978-657-4169
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49802207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3033414Medicaid
MA3033414Medicaid
MAA59312Medicare UPIN