=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952437188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FATHYEH FARNAZ MARVASTI, M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 660 BOSTON RD
-----------------------------------------------------
City | BILLERICA
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01821-5318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-663-8889
-----------------------------------------------------
Fax | 978-663-7542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 BOSTON RD
-----------------------------------------------------
City | BILLERICA
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01821-5318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-663-8889
-----------------------------------------------------
Fax | 978-663-7542
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. FATHYEH FARNAZ MARVASTI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 978-663-8889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 81691
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------