Provider Demographics
NPI:1932373552
Name:PODKOWA, JOHN J JR (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:PODKOWA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:STE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:208 MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5208
Practice Address - Country:US
Practice Address - Phone:508-996-1800
Practice Address - Fax:508-992-7906
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239926207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110082851AMedicaid
MA001276402Medicare PIN