Provider Demographics
NPI:1457333023
Name:EVJY, JACK T (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:EVJY
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 1:10 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1281
Mailing Address - Country:US
Mailing Address - Phone:617-479-1437
Mailing Address - Fax:617-479-3500
Practice Address - Street 1:10 WILLARD ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1281
Practice Address - Country:US
Practice Address - Phone:617-479-1452
Practice Address - Fax:617-479-3500
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA27139207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA14331OtherHARVARD PILGRIM
MA2093472Medicaid
MAM07140OtherBLUE CROSS BLUE SHIELD
MA27139OtherTUFTS HEALTH CARE
MA92915OtherAETNA US HEALTH
MAA65841Medicare UPIN
MA14331OtherHARVARD PILGRIM