Provider Demographics
NPI:1528035276
Name:FAZZIO, FRANK J JR (MD)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:J
Last Name:FAZZIO
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:7301 W EMERALD ST
Mailing Address - Street 2:STE 102
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8688
Mailing Address - Country:US
Mailing Address - Phone:208-321-8600
Mailing Address - Fax:208-321-8626
Practice Address - Street 1:7301 W EMERALD ST
Practice Address - Street 2:STE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8688
Practice Address - Country:US
Practice Address - Phone:208-321-8600
Practice Address - Fax:208-321-8626
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2010-06-30
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Provider Licenses
StateLicense IDTaxonomies
IDM3382208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1528035276OtherNPI
ID020051465OtherRAILROAD MEDICARE
ID204186533OtherTAX ID
ID57851OtherBLUE CROSS
ID1528035276OtherNPI
ID1135026Medicare PIN