Healthcare Provider Details

I. General information

NPI: 1366927543
Provider Name (Legal Business Name): JORDAN HEIFETZ GOLDBERG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 LINCOLN ST STE 203
FRAMINGHAM MA
01702-8264
US

IV. Provider business mailing address

61 LINCOLN ST STE 203
FRAMINGHAM MA
01702-8264
US

V. Phone/Fax

Practice location:
  • Phone: 781-666-2711
  • Fax: 781-666-2712
Mailing address:
  • Phone: 781-666-2711
  • Fax: 781-666-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6747
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: