Healthcare Provider Details

I. General information

NPI: 1740193432
Provider Name (Legal Business Name): VAFA MAMMADOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

4121 HOMESTEAD BLVD
WESTBOROUGH MA
01581-1066
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3021728
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: