Provider Demographics
NPI:1528069804
Name:KOMUTANON, KAJORNDEJ (MD)
Entity type:Individual
Prefix:MR
First Name:KAJORNDEJ
Middle Name:
Last Name:KOMUTANON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6543 W ALBERT AVENUE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-1402
Mailing Address - Country:US
Mailing Address - Phone:847-966-1957
Mailing Address - Fax:773-588-6847
Practice Address - Street 1:3218 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5209
Practice Address - Country:US
Practice Address - Phone:773-588-6846
Practice Address - Fax:733-588-6847
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046966207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036046966Medicaid
IL036046966Medicaid
C42202Medicare UPIN