Healthcare Provider Details

I. General information

NPI: 1912981630
Provider Name (Legal Business Name): JONATHAN M SPECTOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF PEDIATRICS
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

15 LEE ST #5
CAMBRIDGE MA
02139-2252
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-3590
  • Fax:
Mailing address:
  • Phone: 617-953-9471
  • Fax: 508-334-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number205520
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: