Basic Information
| Provider Information | |||||||||
| NPI: | 1972762821 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ETHERIDGE | ||||||||
| FirstName: | LATOYA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 178 SAVIN ST STE 100 | ||||||||
| Address2: | HALLMARK HEALTH MEDICAL ASSOCIATES INC. | ||||||||
| City: | MALDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021483591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813387400 | ||||||||
| FaxNumber: | 7813387405 | ||||||||
| Practice Location | |||||||||
| Address1: | 178 SAVIN ST STE 100 | ||||||||
| Address2: | HALLMARK HEALTH MEDICAL ASSOCIATES INC. | ||||||||
| City: | MALDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021483591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813387400 | ||||||||
| FaxNumber: | 7813387405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 237282 | MA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 249317 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.