Provider Demographics
NPI:1114951241
Name:MELTZER, JACK N (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:N
Last Name:MELTZER
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:
Practice Address - Street 1:2 ESSEX CENTER DR
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2902
Practice Address - Country:US
Practice Address - Phone:978-977-4210
Practice Address - Fax:978-977-4226
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0017391OtherNEIGHBORHOOD HEALTH
MAJ06336OtherBLUE CROSS
MA711678OtherTUFTS
MAHV0021OtherHARVARD PILGRIM
MA3022439Medicaid
MAJ06336OtherBLUE CROSS
MAA32890Medicare PIN