Basic Information
| Provider Information | |||||||||
| NPI: | 1417980137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAZEN | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 GROVE ST | ||||||||
| Address2: | STE 305 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020383156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085285392 | ||||||||
| FaxNumber: | 5085412420 | ||||||||
| Practice Location | |||||||||
| Address1: | 835 W CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020383188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085418000 | ||||||||
| FaxNumber: | 5805416749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 38987 | MA | X | Allopathic & Osteopathic Physicians | Pediatrics | 2083P0901X | 38987 | MA | X | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2068044 | 05 | MA | MEDICAID |