Provider Demographics
NPI:1750483202
Name:FAZIO, NELSON M (MD)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:M
Last Name:FAZIO
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 1:133 MONTGOMERY AVE
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-5502
Mailing Address - Country:US
Mailing Address - Phone:914-713-8517
Mailing Address - Fax:914-713-3248
Practice Address - Street 1:133 MONTGOMERY AVE
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-5502
Practice Address - Country:US
Practice Address - Phone:914-713-8517
Practice Address - Fax:914-713-3248
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY21D731Medicare ID - Type UnspecifiedEMPIRE MEDICARE NUMBER
NYA61229Medicare UPIN