Provider Demographics
NPI:1760176671
Name:FAZEKAS, MARY RAPHAELA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RAPHAELA
Last Name:FAZEKAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30793 ATLANTA LN
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1838
Mailing Address - Country:US
Mailing Address - Phone:216-408-2133
Mailing Address - Fax:
Practice Address - Street 1:30793 ATLANTA LN
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1838
Practice Address - Country:US
Practice Address - Phone:216-408-2133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP984315347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker