Provider Demographics
NPI:1710253836
Name:JOHN G. FASICK DPM LLC
Entity Type:Organization
Organization Name:JOHN G. FASICK DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:FASICK
Authorized Official - Suffix:II
Authorized Official - Credentials:DPM
Authorized Official - Phone:504-301-1749
Mailing Address - Street 1:3901 HOUMA BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2930
Mailing Address - Country:US
Mailing Address - Phone:504-301-1749
Mailing Address - Fax:504-301-9451
Practice Address - Street 1:3901 HOUMA BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2930
Practice Address - Country:US
Practice Address - Phone:504-301-1749
Practice Address - Fax:504-301-9451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADPM.PD284R213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty