Provider Demographics
NPI:1104817717
Name:FUSUNYAN, ROBERT D (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:D
Last Name:FUSUNYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:D
Other - Last Name:FU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:44 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420
Mailing Address - Country:US
Mailing Address - Phone:781-862-1652
Mailing Address - Fax:781-862-1652
Practice Address - Street 1:40 2ND AVENUE
Practice Address - Street 2:SUITE 340
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1132
Practice Address - Country:US
Practice Address - Phone:781-466-8967
Practice Address - Fax:781-466-8987
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78425208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA750032OtherTUFTS HEALTH PLAN
MA3159337Medicaid
MAJ17154OtherBCBS MA
MA3159337Medicaid
MA750032OtherTUFTS HEALTH PLAN