Provider Demographics
NPI:1679756704
Name:FATTAL, MICHAEL H (MD,)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:FATTAL
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:54 BAKER AVENUE EXT
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2137
Mailing Address - Country:US
Mailing Address - Phone:978-369-8780
Mailing Address - Fax:978-369-1043
Practice Address - Street 1:54 BAKER AVENUE EXT
Practice Address - Street 2:SUITE 303
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2137
Practice Address - Country:US
Practice Address - Phone:978-369-8780
Practice Address - Fax:978-369-1043
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA246526207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110089465AMedicaid
MA002324801Medicare PIN