Healthcare Provider Details

I. General information

NPI: 1659576189
Provider Name (Legal Business Name): JAIRAM R ESWARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NEVINS STREET SUITE 303
BRIGHTON MA
02135
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-787-8181
  • Fax: 617-787-4644
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2013024713
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: