Provider Demographics
NPI:1629331616
Name:BURKE, JOHANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:NINO GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:40 HOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2705
Mailing Address - Country:US
Mailing Address - Phone:617-629-6180
Mailing Address - Fax:617-629-6041
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144
Practice Address - Country:US
Practice Address - Phone:617-629-6180
Practice Address - Fax:617-629-6041
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2582072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400157573Medicare PIN