Provider Demographics
NPI:1447240635
Name:SOBOTA, JERZY P (MD)
Entity Type:Individual
Prefix:
First Name:JERZY
Middle Name:P
Last Name:SOBOTA
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 WRIGHT ST
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069-1138
Practice Address - Country:US
Practice Address - Phone:413-283-7651
Practice Address - Fax:413-284-5339
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80133207ZP0101X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3198723Medicaid
MA3198723Medicaid
MAEX9089Medicare PIN