Provider Demographics
NPI:1336382373
Name:AFFONSO, JESSE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:AFFONSO
Suffix:
Gender:M
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:PO BOX 64664
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 NORTH ST STE A
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3825
Practice Address - Country:US
Practice Address - Phone:508-568-3761
Practice Address - Fax:508-775-2352
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247176207X00000X
MDD70202207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD146979Y1KMedicare PIN
MD036682000Medicaid