Provider Demographics
NPI:1003863945
Name:FATEHI, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FATEHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31218
Mailing Address - Street 2:OBGYN ASSOCIATES AT LICH
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150
Mailing Address - Country:US
Mailing Address - Phone:914-328-4500
Mailing Address - Fax:845-565-6057
Practice Address - Street 1:97 AMITY ST FL 3
Practice Address - Street 2:OBGYN ASSOCIATES AT LICH
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6004
Practice Address - Country:US
Practice Address - Phone:718-780-1231
Practice Address - Fax:718-780-4987
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194627207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01532058Medicaid
07J291Medicare PIN
NY01532058Medicaid