Provider Demographics
NPI:1487768040
Name:GENDRON, DOUGLAS JOSEPH (DC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JOSEPH
Last Name:GENDRON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107
Mailing Address - Country:US
Mailing Address - Phone:413-746-0504
Mailing Address - Fax:413-746-0508
Practice Address - Street 1:438 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:413-746-0504
Practice Address - Fax:413-746-0508
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1028952OtherFALLON
3065316OtherAETNA
Y36679OtherBCBS MASS INDEMNITY
1601229OtherMASS HEALTH MEDICAID
MA1601229Medicaid
665295OtherACN GROUP
Y45483OtherMEDICARE MASS AREA 99
Y36679OtherBCBS MASS HMO
665295OtherACN
MAY36679OtherBCBS
1028952OtherFALLON
665295OtherACN