Provider Demographics
NPI:1376620310
Name:FAZIO, ROSEANN (DO)
Entity Type:Individual
Prefix:DR
First Name:ROSEANN
Middle Name:
Last Name:FAZIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228
Mailing Address - Country:US
Mailing Address - Phone:718-238-0024
Mailing Address - Fax:
Practice Address - Street 1:7401 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228
Practice Address - Country:US
Practice Address - Phone:718-238-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1643841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
52D021Medicare ID - Type Unspecified
B15926Medicare UPIN