Basic Information
| Provider Information | |||||||||
| NPI: | 1598721524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GULDEMOND | ||||||||
| FirstName: | THEODORE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018904260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817567273 | ||||||||
| FaxNumber: | 7817567274 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SALEM ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018871200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789886000 | ||||||||
| FaxNumber: | 9786574169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 49802 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3033414 | 05 | MA | MEDICAID |