Healthcare Provider Details

I. General information

NPI: 1952357006
Provider Name (Legal Business Name): JONATHAN BRUCE KRUSKAL MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DEACONESS RD WEST 302B
BOSTON MA
02215-5321
US

IV. Provider business mailing address

59 BALDPATE HILL RD
NEWTON MA
02459-2826
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-2519
  • Fax:
Mailing address:
  • Phone: 617-754-2519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number79345
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: