Healthcare Provider Details

I. General information

NPI: 1225093552
Provider Name (Legal Business Name): JONATHAN D PICKER MD,PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

64 GLEN RD #9
BROOKLINE MA
02445-7757
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6394
  • Fax: 617-730-0466
Mailing address:
  • Phone: 617-783-1948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number213029
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: