1104817717 NPI number — DR. ROBERT D FUSUNYAN MD

Table of content: DR. ROBERT D FUSUNYAN MD (NPI 1104817717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104817717 NPI number — DR. ROBERT D FUSUNYAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUSUNYAN
Provider First Name:
ROBERT
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FU
Provider Other First Name:
ROBERT
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104817717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 NORTH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-862-1652
Provider Business Mailing Address Fax Number:
781-862-1652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 2ND AVENUE
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
WALTHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02451-1132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-466-8967
Provider Business Practice Location Address Fax Number:
781-466-8987
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  78425 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0206X , with the licence number: 78425 , 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: 750032 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3159337 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J17154 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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