Provider Demographics
NPI:1326502014
Name:GILLANI, FAWADULHAQ
Entity type:Individual
Prefix:
First Name:FAWADULHAQ
Middle Name:
Last Name:GILLANI
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 1:14 FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-3000
Mailing Address - Country:US
Mailing Address - Phone:617-782-6460
Mailing Address - Fax:
Practice Address - Street 1:14 FORDHAM RD
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-3000
Practice Address - Country:US
Practice Address - Phone:617-782-6460
Practice Address - Fax:508-675-9640
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1583552084P0800X
MA10207382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry