Provider Demographics
NPI:1265422349
Name:FAZZINI, JOSEPH B (OD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:B
Last Name:FAZZINI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT 130 AND N GREENGATE ROAD
Mailing Address - Street 2:NORTH GREENGATE PROFESSIONAL BUILDING
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644
Mailing Address - Country:US
Mailing Address - Phone:724-838-1500
Mailing Address - Fax:724-838-1505
Practice Address - Street 1:RT 130 AND N GREENGATE ROAD
Practice Address - Street 2:NORTH GREENGATE PROFESSIONAL BUILDING
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644
Practice Address - Country:US
Practice Address - Phone:724-838-1500
Practice Address - Fax:724-838-1505
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007011258002Medicaid
T29655Medicare UPIN
FA150832Medicare ID - Type Unspecified