Provider Demographics
NPI:1073586038
Name:DUBNOFF, JERRY S (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:S
Last Name:DUBNOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-8843
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPM237OtherHARVARD PILGRIM
MA3191257Medicaid
MA037794OtherTUFTS
MAM08888OtherBLUE CROSS
MAA66776Medicare UPIN
MAM08888Medicare ID - Type Unspecified