Basic Information
| Provider Information | |||||||||
| NPI: | 1629001904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROCKTON PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 HIGHLAND ST | ||||||||
| Address2: | |||||||||
| City: | STOUGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020723873 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 LIBBY ST | ||||||||
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| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023022949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085846060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | YARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 5085846060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 150780 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.