Provider Demographics
NPI:1205804523
Name:PERSON, JOHN R (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:PERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5 NEPONSET ST FL STREET2
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:508-721-9106
Practice Address - Street 1:385 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2498
Practice Address - Country:US
Practice Address - Phone:508-721-1180
Practice Address - Fax:508-721-9106
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA40651207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0300123OtherEVERCARE
042472266OtherPRIVATE HEALTHCARE SYSTEM
042472266OtherHEALTHCARE VALUE MANAGEME
MA2056402Medicaid
042472266OtherONE HEALTH PLAN
E03011OtherBLUE SHIELD INDEMNITY
1061150OtherFIRST HEALTH
26962OtherCHILDRENS MEDICAL SECURIT
784066OtherMVP HEALTH CARE
E03011OtherBLUE CARE ELECT
26962OtherHEALTHY START
9900032OtherFALLON COMMUNITY HEALTH P
AA5971OtherHARVARD PILGRIM HEALTHCAR
4215725OtherAETNA US HEALTHCARE
2056402OtherWELFARE
3491751OtherCIGNA HEALTH PLAN
070012043Medicare ID - Type UnspecifiedRAILROAD
E03011OtherBLUE SHIELD INDEMNITY
26962OtherCHILDRENS MEDICAL SECURIT
E03011Medicare ID - Type UnspecifiedB