Provider Demographics
NPI:1073586343
Name:DEFAZIO, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:DEFAZIO
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 1:1301 82ND ST
Mailing Address - Street 2:BOX 26
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228
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:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228
Practice Address - Country:US
Practice Address - Phone:718-836-3721
Practice Address - Fax:718-259-6567
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178425207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01223358Medicaid
NY01223358Medicaid
NY51Z743Medicare PIN