Healthcare Provider Details

I. General information

NPI: 1912104860
Provider Name (Legal Business Name): DANAI KHEMASUWAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WARREN ST FL 2
BRIGHTON MA
02135-3601
US

IV. Provider business mailing address

77 WARREN ST FL 2
BRIGHTON MA
02135-3601
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2545
  • Fax: 617-779-6798
Mailing address:
  • Phone: 617-789-2545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number9396470-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: