Provider Demographics
NPI:1154161222
Name:OMID-FARD, NIMA
Entity type:Individual
Prefix:
First Name:NIMA
Middle Name:
Last Name:OMID-FARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT STREET
Mailing Address - Street 2:GRAY 2 ROOM 241 G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-726-8320
Mailing Address - Fax:617-724-3338
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:GRAY 2 ROOM 241 G
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-8320
Practice Address - Fax:617-724-3338
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10182232085D0003X, 2085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology