Provider Demographics
NPI:1841334539
Name:ROOT, FAYETTE C (MD)
Entity type:Individual
Prefix:
First Name:FAYETTE
Middle Name:C
Last Name:ROOT
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 1:91 BELCHER AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4105
Mailing Address - Country:US
Mailing Address - Phone:508-586-7403
Mailing Address - Fax:
Practice Address - Street 1:91 BELCHER AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4105
Practice Address - Country:US
Practice Address - Phone:508-586-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34315207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology