Provider Demographics
NPI:1528019775
Name:FATTAHY, MARYAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:FATTAHY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1552
Mailing Address - Country:US
Mailing Address - Phone:781-850-2069
Mailing Address - Fax:
Practice Address - Street 1:407 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1552
Practice Address - Country:US
Practice Address - Phone:781-850-2069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0371700Medicaid
U67614Medicare UPIN
MA0371700Medicaid
MAW1717604Medicare PIN