Provider Demographics
NPI:1932247061
Name:FANG, JUNJIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNJIE
Middle Name:
Last Name:FANG
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 1:2 OLD BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-2327
Mailing Address - Country:US
Mailing Address - Phone:774-241-0450
Mailing Address - Fax:774-241-0583
Practice Address - Street 1:118 MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1533
Practice Address - Country:US
Practice Address - Phone:774-241-0450
Practice Address - Fax:774-241-0583
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA238587207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001041401Medicare PIN
MA001041403Medicare PIN
MA001041401Medicare PIN
KYP00449261OtherRAILROAD MEDICARE
KY0998883Medicare PIN