Healthcare Provider Details

I. General information

NPI: 1659372399
Provider Name (Legal Business Name): JOHN A. MAGNOTTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 HIGHLAND AVE
FALL RIVER MA
02720-3703
US

IV. Provider business mailing address

200 MILL RD SUITE 180
FAIRHAVEN MA
02719-5252
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-7643
  • Fax: 508-973-7650
Mailing address:
  • Phone: 508-973-2784
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number58901
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: