Provider Demographics
NPI:1275094922
Name:FARAGON, CORY DESOLE (MD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:DESOLE
Last Name:FARAGON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2908
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL DEPT OF
Practice Address - Street 2:DEPARTMENT OF ANESTHESIA
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-638-6950
Practice Address - Fax:617-638-6966
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
MA1014628207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110155187AMedicaid