NPIMap

Individual provider Active NPI

Gvantsa Didebulidze, M.D

  • Internal Medicine Physician
  • Brockton, MA
National Provider Identifier
1730474644
Registry record updated May 19, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
257775 Issued in MA
Practice address
63 Main St
Brockton, MA 02301-4042
Phone
(508) 559-6699
Fax
(508) 559-5073
NPI assigned
Jun 20, 2011
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 19, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 257775 MA Primary

Addresses

Primary practice location

63 Main St
Brockton, MA 02301-4042

Mailing address

63 Main St
Brockton, MA 02301-4042
Phone (508) 559-6699

Other practice location 1

67 South Bedford Street
Burlington, MA 01805-4042
Phone (781) 744-8000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20141024000170 MA Practitioner - Internal MedicinePractitioner - Hospitalist 0143441758 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Internal MedicineAlso: Hospitalist
Education
Other, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Select Rehabilitation, LLCGroup PAC ID 9032020490, 1,935 clinicians
Lahey Clinic IncGroup PAC ID 2264336528, shared by 3 NPIs, 1,381 clinicians

Practice addresses (Care Compare)

2600 Compass Rd
Glenview, IL 60026-8001

29 Mall Rd
Burlington, MA 01805-0001

41 Mall Rd
Burlington, MA 01805-0001

81 Highland Ave
Salem, MA 01970-2714
Phone (978) 354-2551

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
257775MAMDPediatric Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Lahey Clinic, Inc Internal Medicine CurrentSince Apr 1, 2025 Accepting new patients
Mass General Brigham Medical Group Northern Massachusetts Inc Internal Medicine CurrentSince Sep 1, 2018 Accepting new patients
Brockton Neighborhood Health Center, Inc. CurrentSince Sep 22, 2014 Accepting new patients
Lahey Clinic, Inc. Internal Medicine CurrentSince Apr 1, 2025 Accepting new patients
Brockton Neighborhood Health Center CurrentSince Sep 22, 2014 Accepting new patients

Locations

63 Main St
Brockton, MA 02301
Phone (508) 559-6696

41 Mall Rd
Burlington, MA 01805
Phone (781) 744-8400

67 S Bedford St
Ste 202E
Burlington, MA 01803
Phone (781) 744-7000

67 S Bedford St
Burlington, MA 01803
Phone (781) 744-5115

1 Hutchinson Dr
Danvers, MA 01923
Phone (978) 739-6950

81 Highland Ave
Salem, MA 01970
Phone (978) 354-4009

Interoperability endpoints

  • FHIR API: https://epicproxy.et1290.epichosted.com/FHIRProxy/api/FHIR/R4/

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 10

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1308528000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1747612800000",
    "number": "1730474644",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "63 MAIN ST",
            "city": "BROCKTON",
            "state": "MA",
            "postal_code": "023014042",
            "telephone_number": "508-559-6699",
            "fax_number": "508-559-5073"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "63 MAIN ST",
            "city": "BROCKTON",
            "state": "MA",
            "postal_code": "023014042",
            "telephone_number": "508-559-6699",
            "fax_number": "508-559-5073"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "67 South Bedford Street",
            "address_purpose": "LOCATION",
            "city": "Burlington",
            "state": "MA",
            "postal_code": "018054042",
            "country_code": "US",
            "telephone_number": "781-744-8000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DIDEBULIDZE",
        "first_name": "GVANTSA",
        "credential": "M.D",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-06-20",
        "last_updated": "2025-05-19",
        "certification_date": "2025-05-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MA",
            "license": "257775",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Brockton, MA

Sources for this page

Verify at the official NPI Registry.