Provider Demographics
NPI:1801997564
Name:BARRAVECCHIO, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BARRAVECCHIO
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 1:35 UNITED DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1027
Mailing Address - Country:US
Mailing Address - Phone:508-238-8646
Mailing Address - Fax:508-230-9772
Practice Address - Street 1:26 HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186
Practice Address - Country:US
Practice Address - Phone:617-364-4380
Practice Address - Fax:617-364-7363
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA049287207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0116793Medicaid
A54813Medicare UPIN
MA0116793Medicaid