Healthcare Provider Details

I. General information

NPI: 1205254638
Provider Name (Legal Business Name): RICHARD MARK FAZIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 WESTCHESTER AVE
PURCHASE NY
10577-2574
US

IV. Provider business mailing address

3030 WESTCHESTER AVE
PURCHASE NY
10577-2574
US

V. Phone/Fax

Practice location:
  • Phone: 914-831-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number292288
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: