Healthcare Provider Details

I. General information

NPI: 1528059045
Provider Name (Legal Business Name): HILARY FAZZONE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 STEVENS AVE MIGNONE MEDICAL EYE CARE PC
MT. VERNON NY
10550
US

IV. Provider business mailing address

400 COLUMBUS AVE CREDENTIALING SPECIALIST
NEW HAVEN CT
06519-1233
US

V. Phone/Fax

Practice location:
  • Phone: 914-664-6001
  • Fax: 914-668-0110
Mailing address:
  • Phone: 203-503-3174
  • Fax: 203-503-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number215120
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: