Healthcare Provider Details

I. General information

NPI: 1275620320
Provider Name (Legal Business Name): THOMAS DAG HORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2696
US

V. Phone/Fax

Practice location:
  • Phone: 176-658-9300
  • Fax:
Mailing address:
  • Phone: 176-586-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberE-1269
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberE-1269
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: