Provider Demographics
NPI:1952357006
Name:KRUSKAL, JONATHAN BRUCE (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRUCE
Last Name:KRUSKAL
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 1:59 BALDPATE HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2826
Mailing Address - Country:US
Mailing Address - Phone:617-754-2519
Mailing Address - Fax:
Practice Address - Street 1:1 DEACONESS RD
Practice Address - Street 2:WEST 302B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5321
Practice Address - Country:US
Practice Address - Phone:617-754-2519
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA793452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3126706Medicaid
J14583Medicare ID - Type Unspecified
MA3126706Medicaid