Healthcare Provider Details

I. General information

NPI: 1154161222
Provider Name (Legal Business Name): NIMA OMID-FARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT STREET GRAY 2 ROOM 241 G
BOSTON MA
02114
US

IV. Provider business mailing address

55 FRUIT STREET GRAY 2 ROOM 241 G
BOSTON MA
02114
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8320
  • Fax: 617-724-3338
Mailing address:
  • Phone: 617-726-8320
  • Fax: 617-724-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number1018223
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number1018223
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1018223
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: