Provider Demographics
NPI:1518938745
Name:TKACZ, JAROSLAW N (MD)
Entity Type:Individual
Prefix:DR
First Name:JAROSLAW
Middle Name:N
Last Name:TKACZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAROSLAW
Other - Middle Name:NICHOLAS
Other - Last Name:TKACZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:801 ALBANY ST FL G
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6610
Practice Address - Fax:617-638-6616
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2097162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110034914AMedicaid
NH3089307Medicaid