Provider Demographics
NPI:1265477491
Name:FAZILI, MOHAMAD YOUSUF (MD)
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:YOUSUF
Last Name:FAZILI
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 1:3469 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-2001
Mailing Address - Country:US
Mailing Address - Phone:716-833-3008
Mailing Address - Fax:716-833-3009
Practice Address - Street 1:3469 HARLEM RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-2001
Practice Address - Country:US
Practice Address - Phone:716-833-3008
Practice Address - Fax:716-833-3009
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123086208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1704040OtherINDEPENDENT HEALTH
NY00657034Medicaid
NY00020506201OtherUNIVERA HEALTHCARE
NY000507548001OtherBLUE CROSS/BLUE SHIELD
NY075481Medicare ID - Type UnspecifiedPROVIDER NUMBER
NY00657034Medicaid