Provider Demographics
NPI:1255476198
Name:MOUCHANTAF, FARES GEORGES (MD)
Entity Type:Individual
Prefix:DR
First Name:FARES
Middle Name:GEORGES
Last Name:MOUCHANTAF
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:LAHEY HOSPITAL AND MEDICAL CENTER
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8480
Mailing Address - Fax:781-744-3443
Practice Address - Street 1:LAHEY HOSPITAL AND MEDICAL CENTER
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8480
Practice Address - Fax:781-744-3443
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA225515207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110075967AMedicaid
MA110075967AMedicaid