Provider Demographics
NPI:1780675751
Name:MUDROCK, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:MUDROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:888 MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-4080
Mailing Address - Country:US
Mailing Address - Phone:781-620-4888
Mailing Address - Fax:781-245-2602
Practice Address - Street 1:888 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-4080
Practice Address - Country:US
Practice Address - Phone:781-620-4888
Practice Address - Fax:781-245-2602
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44046207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0129704Medicaid
MAJ03213Medicare PIN