Provider Demographics
NPI:1811123433
Name:FAZIO, MICHAEL GREGORY (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:FAZIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7147 VISTA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-9317
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:515-875-9233
Practice Address - Street 1:5950 UNIVERSITY AVE STE 145
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8233
Practice Address - Country:US
Practice Address - Phone:515-244-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA648092085R0202X
390200000X
IADO-048722085R0202X
MO20200128002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN