Provider Demographics
NPI:1053385393
Name:VASCONCELLOS, CAROL ANN (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:VASCONCELLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 CHAUNCY ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048
Mailing Address - Country:US
Mailing Address - Phone:508-339-2105
Mailing Address - Fax:508-339-5837
Practice Address - Street 1:205 CHAUNCY ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048
Practice Address - Country:US
Practice Address - Phone:508-339-2105
Practice Address - Fax:508-339-5837
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47907207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3094162Medicaid
MAJ12268Medicare ID - Type Unspecified
MA3094162Medicaid