Provider Demographics
NPI:1720441132
Name:SLOSBERG, JEREMY EZRA (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:EZRA
Last Name:SLOSBERG
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 1:65 LIBBY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2992
Mailing Address - Country:US
Mailing Address - Phone:508-584-6060
Mailing Address - Fax:508-584-4949
Practice Address - Street 1:65 LIBBY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2992
Practice Address - Country:US
Practice Address - Phone:508-584-6060
Practice Address - Fax:508-584-4949
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-02
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA279130208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty