Provider Demographics
NPI:1225236672
Name:KWAN, MICHAEL WYMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WYMAN
Last Name:KWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:261 DERBY ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-1046
Mailing Address - Country:US
Mailing Address - Phone:617-923-7510
Mailing Address - Fax:800-804-7454
Practice Address - Street 1:1575 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4308
Practice Address - Country:US
Practice Address - Phone:617-876-4344
Practice Address - Fax:800-804-7454
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100528208100000X
MA233494208100000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1225236672OtherFALLON CHP
MA3664002OtherCIGNA
MA12656654OtherPHCS
MA9178208OtherAETNA
MA1225236672OtherTUFTS (COMMERCIAL)
MA45188OtherHEALTH NEW ENGLAND
MAAA113632OtherHARVARD PILGRIM HP
MA95638907OtherNETWORK HEALTH
MAJ42759OtherBLUE CROSS BLUE SHIELD OF MASS
MA2146738Medicaid
MA23-06065OtherEVERCARE
MA000000047181OtherBMC HEALTHNET
MA2146738Medicaid