Provider Demographics
NPI:1376960690
Name:BLAU, JESSAMYN (MD)
Entity Type:Individual
Prefix:
First Name:JESSAMYN
Middle Name:
Last Name:BLAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-2935
Mailing Address - Country:US
Mailing Address - Phone:617-284-7000
Mailing Address - Fax:617-284-7080
Practice Address - Street 1:300 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145
Practice Address - Country:US
Practice Address - Phone:617-284-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA273664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine