Provider Demographics
NPI:1972538379
Name:JAKSIC, TOM (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:TOM
Middle Name:
Last Name:JAKSIC
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 TEMPLE ST UNIT 510
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-4273
Mailing Address - Country:US
Mailing Address - Phone:617-840-1941
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:FEGAN 3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-9600
Practice Address - Fax:617-730-0477
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA51940208600000X, 2086S0102X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
F39725Medicare UPIN
J21410Medicare ID - Type Unspecified