Basic Information
Provider Information | |||||||||
NPI: | 1538231428 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAKOMIN | ||||||||
FirstName: | BERNADETTE | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 720 HARRISON AVENUE | ||||||||
Address2: | DOB 503 | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021182371 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174145405 | ||||||||
FaxNumber: | 6174146031 | ||||||||
Practice Location | |||||||||
Address1: | 840 HARRISON AVE | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021182905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6176386610 | ||||||||
FaxNumber: | 6176386616 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 04/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 015421 | ME | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 74259 | MA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0007857055 | 01 | ME | AETNA | OTHER | 2323474 | 01 | ME | AETNA USHC | OTHER | 30004665 | 05 | NH |   | MEDICAID | 317980099 | 05 | ME |   | MEDICAID | E65978 | 01 | ME | HPHC | OTHER | 01Y00677NH01 | 01 | NH | ANTHEM | OTHER | M108755 | 01 | ME | CIGNA | OTHER | 037884 | 01 | ME | ANTHEM | OTHER |