Provider Demographics
NPI:1366694887
Name:FAZIO, CHARLES JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:FAZIO
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 1:401 CARLSON PKWY
Mailing Address - Street 2:MEDICA CP433
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5359
Mailing Address - Country:US
Mailing Address - Phone:952-992-3056
Mailing Address - Fax:
Practice Address - Street 1:401 CARLSON PKWY
Practice Address - Street 2:MEDICA CP433
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5359
Practice Address - Country:US
Practice Address - Phone:952-992-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25504207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine