Provider Demographics
NPI:1528036134
Name:FAZENDEIRO, ROY M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:M
Last Name:FAZENDEIRO
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 1:225 FIELD ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-2134
Mailing Address - Country:US
Mailing Address - Phone:508-999-2981
Mailing Address - Fax:508-910-3395
Practice Address - Street 1:225 FIELD ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2134
Practice Address - Country:US
Practice Address - Phone:508-999-2981
Practice Address - Fax:508-910-3395
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2022079Medicaid
MA2022079Medicaid