Provider Demographics
NPI:1790724995
Name:BUCKWOLD, JONATHAN Y (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:Y
Last Name:BUCKWOLD
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 1:77 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:617-562-5359
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:70 EAST ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-4597
Practice Address - Country:US
Practice Address - Phone:978-687-0151
Practice Address - Fax:617-277-1403
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71982208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3120431Medicaid
MAF74923Medicare UPIN