Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 036046966 | IL |
NPI | 1528069804 |
---|---|
Provider Name | Mr. Kajorndej Komutanon |
First Address | Morton Grove, IL 60053-1402 |
Second Address | Chicago, IL 60625-5209 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 29/11/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036046966 | (05) | IL |
C42202 | (02) |