Basic Information
| Provider Information | |||||||||
| NPI: | 1790724995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCKWOLD | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625359 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 EAST ST | ||||||||
| Address2: | |||||||||
| City: | METHUEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018444597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786870151 | ||||||||
| FaxNumber: | 6172771403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 71982 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3120431 | 05 | MA | MEDICAID |