Provider Demographics
NPI:1619503125
Name:DEFAZIO, MARK (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CHIPMAN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4058
Mailing Address - Country:US
Mailing Address - Phone:781-535-8636
Mailing Address - Fax:
Practice Address - Street 1:185 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1804
Practice Address - Country:US
Practice Address - Phone:617-636-5632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9532225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant