Healthcare Provider Details

I. General information

NPI: 1730185695
Provider Name (Legal Business Name): MICHAEL JOSEPH FAZIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 RESPONSE RD
SACRAMENTO CA
95815-4801
US

IV. Provider business mailing address

1525 RESPONSE RD
SACRAMENTO CA
95815-4801
US

V. Phone/Fax

Practice location:
  • Phone: 916-492-1828
  • Fax: 916-492-1834
Mailing address:
  • Phone: 916-492-1828
  • Fax: 916-492-1834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG059079
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberG059079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: