Healthcare Provider Details

I. General information

NPI: 1619101136
Provider Name (Legal Business Name): JORDAN D PAULSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2009
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FOGG RD # 105
WEYMOUTH MA
02190
US

IV. Provider business mailing address

375 BOYLSTON ST
BROOKLINE MA
02445-6007
US

V. Phone/Fax

Practice location:
  • Phone: 781-624-8448
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number18265
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number254453
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: