Provider Demographics
NPI:1073633723
Name:DEFAZIO, ROBERT A (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 W RAY RD # 17-158
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-7256
Mailing Address - Country:US
Mailing Address - Phone:480-206-9104
Mailing Address - Fax:
Practice Address - Street 1:4050 W RAY RD STE 18
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-7256
Practice Address - Country:US
Practice Address - Phone:480-206-9104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6091111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0944220OtherBLUE CROSS PIN#