Provider Demographics
NPI:1972642460
Name:SHONKOFF, JACK P (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:SHONKOFF
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 1:505 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6398
Mailing Address - Country:US
Mailing Address - Phone:617-496-1224
Mailing Address - Fax:
Practice Address - Street 1:50 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-3726
Practice Address - Country:US
Practice Address - Phone:617-496-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37874208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics