Provider Demographics
NPI:1912970633
Name:BRACKETT, ETHAN S (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:S
Last Name:BRACKETT
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 1:142 BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5100
Mailing Address - Country:US
Mailing Address - Phone:617-247-7555
Mailing Address - Fax:
Practice Address - Street 1:142 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5100
Practice Address - Country:US
Practice Address - Phone:617-247-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0145670Medicaid
MA0145670Medicaid