Basic Information
| Provider Information | |||||||||
| NPI: | 1194956573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEFLIN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | WHITE 1003 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | WHITE 1003 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177243874 | ||||||||
| FaxNumber: | 6176431384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2009 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 252381 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 099419 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.