Basic Information
| Provider Information | |||||||||
| NPI: | 1659352813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOKUM | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 228 WINN ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018032630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787411200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 81 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787411200 | ||||||||
| FaxNumber: | 9787411200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 08/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 219709 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 470051 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 2074541 | 05 | MA | MEDICAID | J27181 | 01 | MA | BCBS MA | OTHER |