Healthcare Provider Details
I. General information
NPI: 1790724995
Provider Name (Legal Business Name): JONATHAN Y BUCKWOLD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 06/05/2006
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
70 EAST ST
METHUEN MA
01844-4597
US
IV. Provider business mailing address
77 WARREN ST
BRIGHTON MA
02135-3601
US
V. Phone/Fax
- Phone: 978-687-0151
- Fax: 617-277-1403
- Phone: 617-562-5359
- Fax: 617-562-5415
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 71982 |
| License Number State | MA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 3120431 |
| Identifier Type | MEDICAID |
| Identifier State | MA |
| Identifier Issuer | |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone: