Provider Demographics
NPI:1518963610
Name:VERNON, JAMES KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KENNETH
Last Name:VERNON
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 1:2000 WASHINGTON ST
Mailing Address - Street 2:SUITE 365
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1627
Mailing Address - Country:US
Mailing Address - Phone:617-244-5355
Mailing Address - Fax:617-244-8662
Practice Address - Street 1:2000 WASHINGTON STREET
Practice Address - Street 2:SUITE 365
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1627
Practice Address - Country:US
Practice Address - Phone:617-244-5355
Practice Address - Fax:617-244-8662
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29133208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2084228Medicaid
MAB49009Medicare PIN
MAA36651Medicare UPIN