Healthcare Provider Details

I. General information

NPI: 1376390849
Provider Name (Legal Business Name): SEYED MOHAMMAD HOSSEIN TABATABAEI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

160 CAMBRIDGEPARK DR APT 596
CAMBRIDGE MA
02140-3445
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8835
  • Fax:
Mailing address:
  • Phone: 617-678-6092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3015747
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: