1265600779 NPI number — FELICITO L. FALLER, M.D. INC

Table of content: (NPI 1265600779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265600779 NPI number — FELICITO L. FALLER, M.D. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FELICITO L. FALLER, M.D. INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FELICITO L. FALLER, M.D. INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265600779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALDEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02148-7028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-321-3470
Provider Business Mailing Address Fax Number:
781-322-1139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 UPHAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELROSE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02176-3549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-755-0621
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FALLER
Authorized Official First Name:
FELICITO
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER PROPRIETOR
Authorized Official Telephone Number:
781-321-3470

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  32598 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9738738 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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