Provider Demographics
NPI:1235672494
Name:FAZZIO, JAMES VINCENT (RD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:VINCENT
Last Name:FAZZIO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18030 LAMSON RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLYE
Mailing Address - State:CA
Mailing Address - Zip Code:94546-1313
Mailing Address - Country:US
Mailing Address - Phone:510-909-7594
Mailing Address - Fax:
Practice Address - Street 1:18030 LAMSON RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLYE
Practice Address - State:CA
Practice Address - Zip Code:94546-1313
Practice Address - Country:US
Practice Address - Phone:510-909-7594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86056770133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered