Provider Demographics
NPI:1710078076
Name:LATINI, JERILYN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JERILYN
Middle Name:MARIE
Last Name:LATINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 VFW PKWY
Mailing Address - Street 2:MAIL CODE WX-112
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4927
Mailing Address - Country:US
Mailing Address - Phone:857-203-6551
Mailing Address - Fax:857-203-6660
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:MAIL CODE WX-112
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:857-203-6551
Practice Address - Fax:857-203-6660
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7321208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1577485Medicaid
MIH57915Medicare UPIN
AK8EL766Medicare Oscar/Certification
AK8EL766Medicare Oscar/Certification