Provider Demographics
NPI:1780613935
Name:GORODETSKY, JEFFREY S (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:GORODETSKY
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 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:
Practice Address - Street 1:165 MILL ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3289
Practice Address - Country:US
Practice Address - Phone:978-466-3212
Practice Address - Fax:978-534-3581
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053894173000000X
MA262412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07463OtherBLUE CROSS PROVIDER NUMBE
FL550907821OtherTAX ID NUMBER
FLD21226Medicare UPIN
FL07463OtherBLUE CROSS PROVIDER NUMBE