Healthcare Provider Details

I. General information

NPI: 1285690941
Provider Name (Legal Business Name): CALLY GWON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 WASHINGTON ST SUITE 468
NEWTON MA
02462-1650
US

IV. Provider business mailing address

2000 WASHINGTON STREET SUITE 468
NEWTON MA
02462
US

V. Phone/Fax

Practice location:
  • Phone: 617-965-6700
  • Fax: 617-965-5239
Mailing address:
  • Phone: 617-965-6700
  • Fax: 617-965-5239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number204508
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: