Healthcare Provider Details

I. General information

NPI: 1255389425
Provider Name (Legal Business Name): JILL REBECCA SLATER-FREEDBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 BEDFORD STREET LEXINGTON WALTHAM DERMATOLOGY
LEXINGTON MA
02420-4500
US

IV. Provider business mailing address

223 GLEZEN LN
WAYLAND MA
01778-1520
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-2322
  • Fax:
Mailing address:
  • Phone: 781-862-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number77571
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: