Provider Demographics
NPI:1134184161
Name:BADER, WALID G (DO)
Entity type:Individual
Prefix:
First Name:WALID
Middle Name:G
Last Name:BADER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:77 HERRICK ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2734
Mailing Address - Country:US
Mailing Address - Phone:978-927-4110
Mailing Address - Fax:978-232-7057
Practice Address - Street 1:77 HERRICK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2734
Practice Address - Country:US
Practice Address - Phone:978-927-4110
Practice Address - Fax:978-232-7057
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-01-06
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC1117207R00000X
MA224414207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2113601Medicaid
SC011178Medicaid
RIWB58304OtherMEDICAID
SCAA2107Medicare UPIN
MA2113601Medicaid
SC011178Medicaid
SC8291Medicare PIN