Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 59427 | MA |
NPI | 1013994649 |
---|---|
Provider Name | Dr. John J Croke |
First Address | Boston, MA 02118-2371 |
Second Address | Boston, MA 02118-2526 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2005 |
Last Update Date | 20/05/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110056889A | (05) | MA |
G17756 | (02) |