Provider Demographics
NPI:1396711602
Name:DEFAZIO, CHRISTOPHER L (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:L
Last Name:DEFAZIO
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 1:114 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492
Mailing Address - Country:US
Mailing Address - Phone:781-444-1536
Mailing Address - Fax:781-979-3018
Practice Address - Street 1:585 LEBANON ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176
Practice Address - Country:US
Practice Address - Phone:781-979-3635
Practice Address - Fax:781-979-3018
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58772207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
058772OtherTUFTS
MA3042596Medicaid
J07968OtherBCBS
665716OtherHARVARD PILGRIM
D88520Medicare UPIN
J07968OtherBCBS
665716OtherHARVARD PILGRIM