Provider Demographics
NPI:1689801391
Name:FAKHARZADEH, BENJAMIN (MM)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FAKHARZADEH
Suffix:
Gender:M
Credentials:MM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 CRANBERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-1046
Mailing Address - Country:US
Mailing Address - Phone:800-841-5200
Mailing Address - Fax:508-273-1241
Practice Address - Street 1:242 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1336
Practice Address - Country:US
Practice Address - Phone:978-630-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241602207R00000X
MA2737982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine