Provider Demographics
NPI:1891839825
Name:FANOUS, NABIL I (MD)
Entity Type:Individual
Prefix:DR
First Name:NABIL
Middle Name:I
Last Name:FANOUS
Suffix:
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 1:144 BRETTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-2110
Mailing Address - Country:US
Mailing Address - Phone:413-736-4951
Mailing Address - Fax:
Practice Address - Street 1:144 BRETTON RD
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2110
Practice Address - Country:US
Practice Address - Phone:413-736-4951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33548208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAN51616Medicare ID - Type UnspecifiedMEDICARE B PROVIDER NUMBE
MAA68079Medicare UPIN