Basic Information
| Provider Information | |||||||||
| NPI: | 1376578534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMARKLES | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019492446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 HERRICK ST | ||||||||
| Address2: | STE 101 MEDICAL GROUP INC | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019153012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 01/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 56951 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2019108 | 05 | MA | MEDICAID |