Healthcare Provider Details

I. General information

NPI: 1619503125
Provider Name (Legal Business Name): MARK DEFAZIO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 HARRISON AVE
BOSTON MA
02111-1804
US

IV. Provider business mailing address

39 CHIPMAN ST
MEDFORD MA
02155-4058
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-5632
  • Fax:
Mailing address:
  • Phone: 781-535-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9532
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: