Provider Demographics
NPI:1831194398
Name:FAZIO, DOREEN T (MD)
Entity type:Individual
Prefix:DR
First Name:DOREEN
Middle Name:T
Last Name:FAZIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DOREEN
Other - Middle Name:T
Other - Last Name:FAZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:14914 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2113
Mailing Address - Country:US
Mailing Address - Phone:818-787-2020
Mailing Address - Fax:818-787-8652
Practice Address - Street 1:14914 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2113
Practice Address - Country:US
Practice Address - Phone:818-787-2020
Practice Address - Fax:818-787-8652
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG041260207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063310Medicaid
CAW13323OtherGROUP ID
CAWG41260EOtherPPIN
CAZZZ91696ZOtherBLUE SHIELD
CAZZZ91696ZOtherBLUE SHIELD
CAA48510Medicare UPIN