Provider Demographics
NPI:1972500528
Name:FAZIO, IGNAZIO (MD)
Entity Type:Individual
Prefix:DR
First Name:IGNAZIO
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 1:342 HAMBURG TPKE
Mailing Address - Street 2:STE 201
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2162
Mailing Address - Country:US
Mailing Address - Phone:973-389-1119
Mailing Address - Fax:973-389-1145
Practice Address - Street 1:342 HAMBURG TPKE
Practice Address - Street 2:STE 201
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2162
Practice Address - Country:US
Practice Address - Phone:973-389-1119
Practice Address - Fax:973-389-1145
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06047400207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6236502Medicaid
G07338Medicare UPIN
NJV1524750Medicare ID - Type Unspecified