Basic Information
| Provider Information | |||||||||
| NPI: | 1114909298 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAGAN | ||||||||
| FirstName: | WALT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WILLARD ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021691281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174791437 | ||||||||
| FaxNumber: | 6174793500 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 WILLARD ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021691281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174791437 | ||||||||
| FaxNumber: | 6174793500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 45805 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | B20028501 | 01 | MA | CIGNA | OTHER | B49039 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 21722 | 01 | MA | AETNA US HEALTH | OTHER | 66033 | 01 | MA | HARVARD PILGRIM | OTHER | 45805 | 01 | MA | TUFTS HEALTH CARE | OTHER | 0151505 | 05 | MA | MEDICAID |