Provider Demographics
NPI:1639155013
Name:WARSTADT, GARY M (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:WARSTADT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368
Mailing Address - Country:US
Mailing Address - Phone:781-963-7775
Mailing Address - Fax:781-963-7776
Practice Address - Street 1:1093 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368
Practice Address - Country:US
Practice Address - Phone:781-963-7775
Practice Address - Fax:781-963-7776
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA575692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3019454Medicaid
MA3019454Medicaid
MAJ06399Medicare ID - Type Unspecified