Healthcare Provider Details

I. General information

NPI: 1952468985
Provider Name (Legal Business Name): RAPEEPAN S KOMUTANON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3218 W LAWRENCE AVENUE
CHICAGO IL
60625
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: 773-588-6847
Mailing address:
  • Phone: 847-966-1957
  • Fax: 773-588-6847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: