Provider Demographics
NPI:1609367465
Name:DEFAZIO, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6755 SHELTER LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4369
Mailing Address - Country:US
Mailing Address - Phone:702-521-2350
Mailing Address - Fax:
Practice Address - Street 1:6755 SHELTER LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4369
Practice Address - Country:US
Practice Address - Phone:702-521-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-28
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1953895172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty