Provider Demographics
NPI:1619990496
Name:BUENO, JACK THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:THOMAS
Last Name:BUENO
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 1:2300 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1818
Mailing Address - Country:US
Mailing Address - Phone:603-577-4000
Mailing Address - Fax:
Practice Address - Street 1:2300 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1818
Practice Address - Country:US
Practice Address - Phone:603-577-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11347207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30203354Medicaid
NH30203354Medicaid
NHRE6438Medicare PIN