Provider Demographics
NPI:1639218845
Name:FAZILI, ABDUL Q (MD)
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:Q
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 1:9040 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031-1934
Mailing Address - Country:US
Mailing Address - Phone:716-631-0621
Mailing Address - Fax:716-631-3431
Practice Address - Street 1:9040 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1934
Practice Address - Country:US
Practice Address - Phone:716-631-0621
Practice Address - Fax:716-631-3431
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1191141207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0400538OtherIHA PROVIDER
000506313003OtherCB PROVIDER
NY00604664Medicaid
00010054001OtherUNIVERA HEALTHCARE
166177308OtherUNITED HEALTHCARE
NY00604664Medicaid
000506313003OtherCB PROVIDER