Provider Demographics
NPI:1639142177
Name:FAZIO, GAETANO THOMAS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GAETANO
Middle Name:THOMAS
Last Name:FAZIO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:G
Other - Middle Name:THOMAS
Other - Last Name:FAZIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2665 DERR RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2445
Mailing Address - Country:US
Mailing Address - Phone:937-342-9820
Mailing Address - Fax:937-342-9820
Practice Address - Street 1:2665 DERR RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2445
Practice Address - Country:US
Practice Address - Phone:937-342-9801
Practice Address - Fax:937-342-9804
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35025852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2675654Medicaid
OH2675654Medicaid
OHE29706Medicare UPIN