Provider Demographics
NPI:1487672168
Name:ITANI, KAMAL MF (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMAL
Middle Name:MF
Last Name:ITANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1400 VFW PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4927
Mailing Address - Country:US
Mailing Address - Phone:857-203-6202
Mailing Address - Fax:857-202-5549
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:857-203-6205
Practice Address - Fax:857-202-5549
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA220586208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81Z756Medicare ID - Type Unspecified