Basic Information
Provider Information | |||||||||
NPI: | 1699761965 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALI-KHAN | ||||||||
FirstName: | FAUZIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 61 LINCOLN ST STE 203 | ||||||||
Address2: |   | ||||||||
City: | FRAMINGHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 017028264 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7138936214 | ||||||||
FaxNumber: | 4014143486 | ||||||||
Practice Location | |||||||||
Address1: | 63 EDDIE DOWLING HWY STE 9 | ||||||||
Address2: |   | ||||||||
City: | NORTH SMITHFIELD | ||||||||
State: | RI | ||||||||
PostalCode: | 028967322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014143485 | ||||||||
FaxNumber: | 4014143486 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2005 | ||||||||
LastUpdateDate: | 03/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 219392 | MA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD16933 | RI | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 110035934A | 05 | MA |   | MEDICAID | 2034191 | 05 | MA |   | MEDICAID |