Provider Demographics
NPI:1942205620
Name:FADER, PAUL FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:FREDERICK
Last Name:FADER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 598
Mailing Address - Street 2:
Mailing Address - City:HARWICH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02646-0598
Mailing Address - Country:US
Mailing Address - Phone:508-905-2800
Mailing Address - Fax:508-487-6298
Practice Address - Street 1:49 HARRY KEMP WAY
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1618
Practice Address - Country:US
Practice Address - Phone:508-487-9395
Practice Address - Fax:508-487-6298
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ07630799XOtherSTATE TAX ID NUMBER
AZ07630799XOtherSTATE TAX ID NUMBER
AZ07630799XOtherSTATE TAX ID NUMBER
AZ860680385OtherFEDERAL TAX ID NUMBER