Basic Information
Provider Information
NPI: 1003291279
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BOFARRAG
FirstName: FADEL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5870 HIATUS RD
Address2:  
City: TAMARAC
State: FL
PostalCode: 333216424
CountryCode: US
TelephoneNumber: 9543773025
FaxNumber: 3144345939
Practice Location
Address1: 585 LEBANON ST
Address2:  
City: MELROSE
State: MA
PostalCode: 021763225
CountryCode: US
TelephoneNumber: 8004243672
FaxNumber: 3144345939
Other Information
ProviderEnumerationDate: 07/29/2015
LastUpdateDate: 02/02/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/02/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X276951MAN Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000X2015014044MON Allopathic & Osteopathic PhysiciansInternal Medicine 
208M00000X276951MAY Allopathic & Osteopathic PhysiciansHospitalist 

No ID Information.


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