Healthcare Provider Details

I. General information

NPI: 1528069804
Provider Name (Legal Business Name): KAJORNDEJ KOMUTANON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 11/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3218 W LAWRENCE AVE
CHICAGO IL
60625-5209
US

IV. Provider business mailing address

6543 W ALBERT AVENUE
MORTON GROVE IL
60053-1402
US

V. Phone/Fax

Practice location:
  • Phone: 773-588-6846
  • Fax: 733-588-6847
Mailing address:
  • Phone: 847-966-1957
  • Fax: 773-588-6847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036046966
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: