Provider Demographics
NPI:1639469463
Name:FAZEKAS, MATTHEW L (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:FAZEKAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:1150 N 35TH AVE
Practice Address - Street 2:SUITE 345
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-265-6300
Practice Address - Fax:954-961-3600
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2021-03-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME1244792080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015053000Medicaid
FLIG216ZOtherMEDICARE PTAN