Provider Demographics
NPI:1538231428
Name:JAKOMIN, BERNADETTE V (MD)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:V
Last Name:JAKOMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6610
Practice Address - Fax:617-638-6616
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0154212085R0202X
MA742592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3117609Medicaid
ME317980099Medicaid
MA110050366AMedicaid
ME317980099Medicaid
MEE65978OtherHPHC
NH01Y00677NH01OtherANTHEM
MEM108755OtherCIGNA
ME037884OtherANTHEM
NH01Y00677NH01OtherANTHEM
ME300104867Medicare ID - Type UnspecifiedRAILROAD
MEMM8023Medicare ID - Type Unspecified
NH30004665Medicaid
ME2323474OtherAETNA USHC