Provider Demographics
NPI:1447594916
Name:DE FAZIO OBSTETRICS & GYNECOLOGY, PC
Entity type:Organization
Organization Name:DE FAZIO OBSTETRICS & GYNECOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DE FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-836-3721
Mailing Address - Street 1:1301 82ND ST
Mailing Address - Street 2:BOX 26
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3007
Mailing Address - Country:US
Mailing Address - Phone:718-836-3721
Mailing Address - Fax:718-259-6567
Practice Address - Street 1:1301 82ND ST
Practice Address - Street 2:BOX 26
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-3007
Practice Address - Country:US
Practice Address - Phone:718-836-3721
Practice Address - Fax:718-259-6567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178425207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty