Provider Demographics
NPI:1568579142
Name:MOUSSALLY, JON S (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:S
Last Name:MOUSSALLY
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 1:22 CHAUNCY ST
Mailing Address - Street 2:APARTMENT #18
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-2425
Mailing Address - Country:US
Mailing Address - Phone:617-233-5368
Mailing Address - Fax:
Practice Address - Street 1:81 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2714
Practice Address - Country:US
Practice Address - Phone:978-354-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226564207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine