Healthcare Provider Details

I. General information

NPI: 1821354325
Provider Name (Legal Business Name): MICHAEL VINCENT DEFAZIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14546 OLD SAINT AUGUSTINE RD STE 407
JACKSONVILLE FL
32258-5473
US

IV. Provider business mailing address

11945 SAN JOSE BLVD STE 300
JACKSONVILLE FL
32223-1627
US

V. Phone/Fax

Practice location:
  • Phone: 904-262-3372
  • Fax: 904-262-3306
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-396-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberR6770
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: