Provider Demographics
NPI:1992159917
Name:FORD, JEREMY N
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:N
Last Name:FORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:336-832-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC218456207R00000X
MA2868602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine