Provider Demographics
NPI:1407883150
Name:FAZZINI, ENRICO (DO)
Entity Type:Individual
Prefix:
First Name:ENRICO
Middle Name:
Last Name:FAZZINI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108-14 72ND AVENUE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-263-5600
Mailing Address - Fax:
Practice Address - Street 1:108-14 72ND AVENUE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-263-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1575182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTAX IDOtherTIN 133530704
NY16E911Medicare ID - Type Unspecified
NY16E913Medicare PIN
NY16E912Medicare PIN
NY06962Medicare PIN