Basic Information
Provider Information | |||||||||
NPI: | 1053363424 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIGON | ||||||||
FirstName: | KEITH | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 75 FRANCIS STREET | ||||||||
Address2: | AMORY 3 | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177327510 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 75 FRANCIS STREET | ||||||||
Address2: | AMORY 3 | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177327510 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 12/31/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 208878 | MA | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
No ID Information.