Healthcare Provider Details

I. General information

NPI: 1235441429
Provider Name (Legal Business Name): JENNIFER ROSE DEFAZIO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER ROSE MIKSAN

II. Dates (important events)

Enumeration Date: 07/05/2010
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

3959 BROADWAY RM 216B
NEW YORK NY
10032-1559
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number288868-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: