Basic Information
| Provider Information | |||||||||
| NPI: | 1831174416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEGRAND | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | WOT 12TH FL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685424 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | GERIATRICS | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088520600 | ||||||||
| FaxNumber: | 5088537149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 77405 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3114830 | 05 | MA | MEDICAID |