Provider Demographics
NPI:1487185104
Name:FANG, ZACHARY BROOK
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:BROOK
Last Name:FANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 WORCESTER ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-3716
Mailing Address - Country:US
Mailing Address - Phone:781-304-8838
Mailing Address - Fax:
Practice Address - Street 1:981 WORCESTER ST STE 2A
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-3716
Practice Address - Country:US
Practice Address - Phone:780-304-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA2924102086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program