Healthcare Provider Details

I. General information

NPI: 1508916792
Provider Name (Legal Business Name): EDRESS OTHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 MILL RD
FAIRHAVEN MA
02719-5208
US

IV. Provider business mailing address

200 MILL RD SUITE 180
FAIRHAVEN MA
02719-5252
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-3000
  • Fax: 508-973-3119
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number254703
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: