Provider Demographics
NPI:1790737815
Name:DEGRUTTOLA, DANIEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:P
Last Name:DEGRUTTOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3 ELECTRONICS AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-1099
Mailing Address - Country:US
Mailing Address - Phone:978-750-0300
Mailing Address - Fax:
Practice Address - Street 1:12 ROGERS RD
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01835-6925
Practice Address - Country:US
Practice Address - Phone:978-374-7971
Practice Address - Fax:978-374-8354
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81750208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAG79294Medicare UPIN
MAA28816Medicare ID - Type UnspecifiedMC PR #