Healthcare Provider Details

I. General information

NPI: 1205898202
Provider Name (Legal Business Name): JASON VIERECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 HARRISON AVE SUITE 707
BOSTON MA
02118-2371
US

IV. Provider business mailing address

720 HARRISON AVE SUITE 707
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8456
  • Fax: 617-638-8465
Mailing address:
  • Phone: 617-638-8456
  • Fax: 617-638-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number158808
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: