Provider Demographics
NPI:1841298742
Name:FAZZONE, ANTHONY B (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:B
Last Name:FAZZONE
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 1:100 HOSPITAL DR.
Mailing Address - Street 2:SOUTHWESTERN VERMONT HEALTH CARE
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201
Mailing Address - Country:US
Mailing Address - Phone:802-442-6361
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR.
Practice Address - Street 2:SOUTHWESTERN VERMONT HEALTH CARE
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201
Practice Address - Country:US
Practice Address - Phone:802-442-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12375207L00000X
VT042.0010702207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204515Medicaid
NHRE780101Medicare PIN