Provider Demographics
NPI:1891812061
Name:DOVIDIO, KENNETH R (PA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:DOVIDIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 TURNPIKE ST
Mailing Address - Street 2:STE 31
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-5923
Mailing Address - Country:US
Mailing Address - Phone:978-683-4299
Mailing Address - Fax:978-688-9603
Practice Address - Street 1:555 TURNPIKE ST
Practice Address - Street 2:STE 31
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-5923
Practice Address - Country:US
Practice Address - Phone:978-683-4299
Practice Address - Fax:978-688-9603
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP2471Medicare ID - Type Unspecified