Provider Demographics
NPI:1457458929
Name:FAZZALARI, FRANCO L (MD)
Entity Type:Individual
Prefix:
First Name:FRANCO
Middle Name:L
Last Name:FAZZALARI
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 1:311 MACK AVE STE 64100
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2466
Mailing Address - Country:US
Mailing Address - Phone:313-832-0650
Mailing Address - Fax:313-993-0447
Practice Address - Street 1:311 MACK AVE STE 64100
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2466
Practice Address - Country:US
Practice Address - Phone:313-832-0650
Practice Address - Fax:313-993-0447
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056091208G00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4649218Medicaid
MI4649218Medicaid
MI0P11220002Medicare ID - Type Unspecified