Provider Demographics
NPI:1851374110
Name:KETRO, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:KETRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 REVERE ST
Mailing Address - Street 2:ELL POND MEDICAL ASSOCIATES INC ATTN JUNE VINARD
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4543
Mailing Address - Country:US
Mailing Address - Phone:781-286-1313
Mailing Address - Fax:781-286-1098
Practice Address - Street 1:425 REVERE ST
Practice Address - Street 2:ELL POND MEDICAL ASSOCIATES INC
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-4543
Practice Address - Country:US
Practice Address - Phone:781-286-1313
Practice Address - Fax:781-286-1098
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA77202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3112004Medicaid
F61488Medicare UPIN
MAJ14034Medicare ID - Type Unspecified