Provider Demographics
NPI:1790832913
Name:FATHALLAH, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:FATHALLAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-2443
Mailing Address - Country:US
Mailing Address - Phone:508-226-4455
Mailing Address - Fax:
Practice Address - Street 1:146 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2443
Practice Address - Country:US
Practice Address - Phone:508-226-4455
Practice Address - Fax:508-222-6778
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47039207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9722335Medicaid
MAM13478OtherMASSBCBS
RI410904OtherRIBCBS
MAM13478OtherMASSBCBS
MA9722335Medicaid