Healthcare Provider Details

I. General information

NPI: 1932593597
Provider Name (Legal Business Name): MICHELLE FAKLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2015
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MOUNT AUBURN ST DEPT OF
CAMBRIDGE MA
02138-5502
US

IV. Provider business mailing address

330 BROOKLINE AVE DEPARTMENT OF SURGERY
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-499-5719
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number275119
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: