Provider Demographics
NPI:1417980137
Name:FAZEN, LOUIS E III (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:E
Last Name:FAZEN
Suffix:III
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 1:124 GROVE ST
Mailing Address - Street 2:STE 305
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-3156
Mailing Address - Country:US
Mailing Address - Phone:508-528-5392
Mailing Address - Fax:508-541-2420
Practice Address - Street 1:835 W CENTRAL ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-3188
Practice Address - Country:US
Practice Address - Phone:508-541-8000
Practice Address - Fax:580-541-6749
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38987208000000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2068044Medicaid
N01675Medicare ID - Type Unspecified
E02116Medicare UPIN