Healthcare Provider Details

I. General information

NPI: 1902877806
Provider Name (Legal Business Name): GHALEB H DAOUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

4 ROSS RD
BELMONT MA
02478-2115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6129
  • Fax: 617-730-0569
Mailing address:
  • Phone: 617-489-0928
  • Fax: 617-489-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number72324
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: