1104515659 NPI number — DR. KEVIN GHAISS MAKHOUL MD

Table of content: DR. KEVIN GHAISS MAKHOUL MD (NPI 1104515659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104515659 NPI number — DR. KEVIN GHAISS MAKHOUL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAKHOUL
Provider First Name:
KEVIN
Provider Middle Name:
GHAISS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104515659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 BROOKLINE AVE
Provider Second Line Business Mailing Address:
RABB CLINIC, 2ND FLOOR, ATTN: KEVIN MAKHOUL
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02215-5491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-667-3455
Provider Business Mailing Address Fax Number:
617-667-5575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 BROOKLINE AVE
Provider Second Line Business Practice Location Address:
RABB CLINIC, 2ND FLOOR
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215-5491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-667-3455
Provider Business Practice Location Address Fax Number:
617-667-5575
Provider Enumeration Date:
05/02/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , with the licence number:  3017415 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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