Provider Demographics
NPI:1669895181
Name:HADDOCK, LOUISE
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:HADDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6393
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-0017
Mailing Address - Country:US
Mailing Address - Phone:617-447-9800
Mailing Address - Fax:
Practice Address - Street 1:12 HADLEY PL
Practice Address - Street 2:#2
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3905
Practice Address - Country:US
Practice Address - Phone:617-447-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAXXM981581399OtherBCBS
MAXXM981581399Medicare PIN