Provider Demographics
NPI:1336307941
Name:FAZALARE, JOSEPH J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:J
Last Name:FAZALARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3500
Mailing Address - Fax:681-342-3507
Practice Address - Street 1:527 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9010
Practice Address - Country:US
Practice Address - Phone:681-342-3500
Practice Address - Fax:681-342-3507
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24001207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4293261OtherMEDICARE PTAN
WV3810018178OtherMEDICAID
WV3810018178OtherMEDICAID