Provider Demographics
NPI:1205803798
Name:DODEK, ANTON BLAINE (MD)
Entity type:Individual
Prefix:DR
First Name:ANTON
Middle Name:BLAINE
Last Name:DODEK
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 1:23 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-4020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2351
Practice Address - Country:US
Practice Address - Phone:781-828-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74229208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF26452Medicare UPIN