Provider Demographics
NPI:1942243704
Name:FAZAL, JAVED H (MD)
Entity Type:Individual
Prefix:
First Name:JAVED
Middle Name:H
Last Name:FAZAL
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 1:1860 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3612
Mailing Address - Country:US
Mailing Address - Phone:478-225-9001
Mailing Address - Fax:478-225-9167
Practice Address - Street 1:1860 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3612
Practice Address - Country:US
Practice Address - Phone:478-225-9001
Practice Address - Fax:478-225-9167
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA138340105EMedicaid
GAH34245Medicare PIN
GA138340105EMedicaid