Provider Demographics
NPI:1245231083
Name:DIFAZIO, LOUIS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:JOHN
Last Name:DIFAZIO
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 1:2371 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-8113
Mailing Address - Country:US
Mailing Address - Phone:718-364-6199
Mailing Address - Fax:718-364-6502
Practice Address - Street 1:2371 ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-8113
Practice Address - Country:US
Practice Address - Phone:718-364-6199
Practice Address - Fax:718-364-6502
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151941-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY35D611OtherPTAN
NY00872546Medicaid
NYA62427Medicare UPIN