Healthcare Provider Details

I. General information

NPI: 1427288901
Provider Name (Legal Business Name): JENNIFER LEE BOGDANOVITCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LEE SEBASTIANELLI MD

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 MAIN ST UNIT 4
MEDFIELD MA
02052-2043
US

IV. Provider business mailing address

PO BOX 469
MEDFIELD MA
02052-0469
US

V. Phone/Fax

Practice location:
  • Phone: 508-359-8141
  • Fax: 508-359-8005
Mailing address:
  • Phone: 508-359-8141
  • Fax: 508-359-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number241947
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: