Healthcare Provider Details

I. General information

NPI: 1053506618
Provider Name (Legal Business Name): HAEWOOK HAN PHD, RD, CSR, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

133 BROOKLINE AVE NEPHROLOGY DEPARTMENT
BOSTON MA
02215-3904
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1380
  • Fax: 617-421-2115
Mailing address:
  • Phone: 617-421-1126
  • Fax: 617-421-1066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1706
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: