Individual
SAN WAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
46315
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0156736
—
MA
01
—
01Y000581MA01
ANTHEM
—
01
—
0300380
UNITED HEALTHCARE
—
01
—
2430963
AETNA
—
01
—
401197
HARVARD PILGRIM HEALTHCAR
MA
01
—
713618
TUFTS HEALTH PLANS
MA
01
—
B20406102
CIGNA
—
01
—
B36040
BLUE CROSS BLUE SHIELD OF
MA
01
—
P00034200
RAILROAD MEDICARE
—
Enumeration date
02/04/2006
Last updated
07/13/2026
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