Provider Demographics
NPI:1851357750
Name:DE ZENGOTITA, JUAN JAIME (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:JAIME
Last Name:DE ZENGOTITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:640 CENTRE STREET
Mailing Address - Street 2:SOUTHERN JAMAICA PLAIN HEALTH CENTER
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-983-4100
Mailing Address - Fax:617-524-5170
Practice Address - Street 1:1340 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4302
Practice Address - Country:US
Practice Address - Phone:617-983-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA205566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110000392AMedicaid