Provider Demographics
NPI:1265692859
Name:DR. DALE FAZIO FOOT CLINIC
Entity type:Organization
Organization Name:DR. DALE FAZIO FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-797-3470
Mailing Address - Street 1:1914 E 70TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5312
Mailing Address - Country:US
Mailing Address - Phone:318-797-3470
Mailing Address - Fax:318-797-9956
Practice Address - Street 1:1914 E 70TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5312
Practice Address - Country:US
Practice Address - Phone:318-797-3470
Practice Address - Fax:318-797-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD009213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1318451Medicaid
LA1318451Medicaid