Provider Demographics
NPI:1861451551
Name:DRAKE, JONATHAN P (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:DRAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SWALLOW LN
Mailing Address - Street 2:
Mailing Address - City:DUNSTABLE
Mailing Address - State:MA
Mailing Address - Zip Code:01827-1206
Mailing Address - Country:US
Mailing Address - Phone:978-649-6871
Mailing Address - Fax:
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2134
Practice Address - Country:US
Practice Address - Phone:978-937-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223799207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ42555OtherBLUE SHIELD
MA2143445Medicaid
MA2143445Medicaid
MAP00464848Medicare PIN