Basic Information
| Provider Information | |||||||||
| NPI: | 1003291279 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOFARRAG | ||||||||
| FirstName: | FADEL | ||||||||
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| Credential: | MD | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2015014044 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 276951 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 276951 | MA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.