Provider Demographics
NPI:1689627465
Name:DEFAZIO, CHRISTIAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:R
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:77 GOODELL ST
Mailing Address - Street 2:DEPT OF EMERGENCY MEDICINE, SUITE 340
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-5906
Mailing Address - Country:US
Mailing Address - Phone:716-645-9700
Mailing Address - Fax:716-456-9701
Practice Address - Street 1:BUFFALO GENERAL MEDICAL CENTER
Practice Address - Street 2:100 HIGH STREET, EMERGENCY DEPARTMENT
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203
Practice Address - Country:US
Practice Address - Phone:716-859-5600
Practice Address - Fax:716-645-9701
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY210627-1207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01881290Medicaid
NYBB9968Medicare PIN