Provider Demographics
NPI:1548215171
Name:FAZILI, TASADUQ N (MD)
Entity Type:Individual
Prefix:
First Name:TASADUQ
Middle Name:N
Last Name:FAZILI
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 1:2001 CRYSTAL SPRING AVE SW STE 301
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2465
Mailing Address - Country:US
Mailing Address - Phone:540-981-7715
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW STE 301
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2465
Practice Address - Country:US
Practice Address - Phone:540-981-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261497207RI0200X
VA0101267456207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03361800Medicaid
NYP01227409OtherRAILROAD MEDICARE
NY03361800Medicaid
H55796Medicare UPIN