Provider Demographics
NPI:1245218353
Name:KRUSKAL, BENJAMIN A (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:A
Last Name:KRUSKAL
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 1:40 HOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2705
Mailing Address - Country:US
Mailing Address - Phone:617-629-6000
Mailing Address - Fax:
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6000
Practice Address - Fax:617-629-6070
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71820208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB10462303OtherCIGNA
MAPP825OtherHARVARD PILGRIM
MA0003938OtherNEIGHBORHOOD HEALTH
MA071820OtherTUFTS
MAJ09980OtherBLUE CROSS
MA3065421Medicaid
MA071820OtherTUFTS
MAPP825OtherHARVARD PILGRIM