Provider Demographics
NPI:1104898022
Name:JEVON, THOMAS RUSSELL (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RUSSELL
Last Name:JEVON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:30 NEWCROSSING RD STE 301
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:MA
Mailing Address - Zip Code:01867-3254
Mailing Address - Country:US
Mailing Address - Phone:781-942-0380
Mailing Address - Fax:781-942-0371
Practice Address - Street 1:30 NEWCROSSING RD STE 301
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:MA
Practice Address - Zip Code:01867-3254
Practice Address - Country:US
Practice Address - Phone:781-942-0380
Practice Address - Fax:781-942-0371
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110044837/AMedicaid
MA110044837/AMedicaid