Provider Demographics
NPI:1225000623
Name:BURKS, ERIC JASON (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JASON
Last Name:BURKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-414-6031
Practice Address - Street 1:670 ALBANY STREET
Practice Address - Street 2:SUITE 304
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2646
Practice Address - Country:US
Practice Address - Phone:617-414-5314
Practice Address - Fax:617-414-5315
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223504207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076181AMedicaid
MAA39723Medicare PIN
MA110076181AMedicaid