Provider Demographics
NPI:1912981630
Name:SPECTOR, JONATHAN M (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:SPECTOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15 LEE ST
Mailing Address - Street 2:#5
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-2252
Mailing Address - Country:US
Mailing Address - Phone:617-953-9471
Mailing Address - Fax:508-334-5201
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA205520208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0132233Medicaid
MA0132233Medicaid
MAH44377Medicare UPIN