Provider Demographics
NPI:1659363679
Name:FAZEKAS, EDWARD A (DPM)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:FAZEKAS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4046
Mailing Address - Country:US
Mailing Address - Phone:863-687-3404
Mailing Address - Fax:863-687-4672
Practice Address - Street 1:2939 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4046
Practice Address - Country:US
Practice Address - Phone:863-687-3404
Practice Address - Fax:863-687-4672
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 0001370213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T55530Medicare UPIN
FL87750Medicare ID - Type Unspecified