Provider Demographics
NPI:1902806219
Name:PERRELLI, W. VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:W. VINCENT
Middle Name:
Last Name:PERRELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-4421
Mailing Address - Country:US
Mailing Address - Phone:781-647-3040
Mailing Address - Fax:781-647-3044
Practice Address - Street 1:671 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-0602
Practice Address - Country:US
Practice Address - Phone:781-647-3040
Practice Address - Fax:781-647-3044
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32113207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2007568Medicaid
MA2007568Medicaid
MDM07988Medicare ID - Type Unspecified