Healthcare Provider Details

I. General information

NPI: 1639121544
Provider Name (Legal Business Name): JACK F BUKOWSKI MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRIGHAM AND WOMEN HOSPITAL DIV OF RHEUMATOLOGY 75 FRANCIS ST
BOSTON MA
02115
US

IV. Provider business mailing address

BRIGHAM AND WOMEN HOSPITAL DIV OF RHEUMATOLOGY 75 FRANCIS ST
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5325
  • Fax:
Mailing address:
  • Phone: 617-732-5325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number73064
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: