Healthcare Provider Details

I. General information

NPI: 1336235639
Provider Name (Legal Business Name): DR. FAZELI & DR. BROUMAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 MEDICAL CENTER DR
FAYETTEVILLE NY
13066-6613
US

IV. Provider business mailing address

4110 MEDICAL CENTER DR
FAYETTEVILLE NY
13066-6613
US

V. Phone/Fax

Practice location:
  • Phone: 315-663-0100
  • Fax: 315-663-0052
Mailing address:
  • Phone: 315-663-0100
  • Fax: 585-663-0052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AMIN FAZELI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 315-663-0100