Provider Demographics
NPI:1366411449
Name:KONKLE, REBECCA L (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:KONKLE
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 1:75 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4960
Mailing Address - Country:US
Mailing Address - Phone:617-495-4414
Mailing Address - Fax:617-495-8090
Practice Address - Street 1:75 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4960
Practice Address - Country:US
Practice Address - Phone:617-495-4414
Practice Address - Fax:617-495-8090
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHV0026OtherHARVARD PILGRIM
MAJ07532OtherBLUE CROSS
MA3034461Medicaid
MA059333OtherTUFTS
MA3034461Medicaid
MAJ07532Medicare PIN