Provider Demographics
NPI:1891823340
Name:FAZIO, DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:FAZIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 COLBY ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2083
Mailing Address - Country:US
Mailing Address - Phone:510-666-0854
Mailing Address - Fax:858-505-7101
Practice Address - Street 1:3000 COLBY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2083
Practice Address - Country:US
Practice Address - Phone:510-666-0854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94253207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1891823340Medicaid