Provider Demographics
NPI:1710069760
Name:PANEZAI, FAZAL R (MD)
Entity Type:Individual
Prefix:DR
First Name:FAZAL
Middle Name:R
Last Name:PANEZAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FAZLUR
Other - Middle Name:R
Other - Last Name:PANEZAI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:177 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3127
Mailing Address - Country:US
Mailing Address - Phone:732-566-6614
Mailing Address - Fax:732-290-9448
Practice Address - Street 1:177 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747
Practice Address - Country:US
Practice Address - Phone:732-566-6614
Practice Address - Fax:732-290-9448
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03349200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2066602-22Medicaid
NJD97054Medicare UPIN