Provider Demographics
NPI:1538258199
Name:KIRICHIAN, JACK M (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:KIRICHIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AGOP
Other - Middle Name:M
Other - Last Name:KIRICHIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 W GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346-1458
Mailing Address - Country:US
Mailing Address - Phone:508-923-6471
Mailing Address - Fax:508-923-6474
Practice Address - Street 1:511 W GROVE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02346-1458
Practice Address - Country:US
Practice Address - Phone:508-923-6471
Practice Address - Fax:508-923-6474
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
495484OtherTUFTS
MA2127491Medicaid
MA1396037OtherAETNA
MAA40623Medicare PIN
495484OtherTUFTS