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General NPI Number Information
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NPI Number | 1265692859
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Entity Type | Organization
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Legal Business Name | DR. DALE FAZIO FOOT CLINIC
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Dates
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Enumeration Date | 06/17/2008
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 1914 E 70TH ST SUITE D
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City | SHREVEPORT
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State | LA
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Zip | 71105-5312
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Country | US
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Telephone | 318-797-3470
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Fax | 318-797-9956
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Provider Business Mailing Address
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Address Line | 1914 E 70TH ST SUITE D
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City | SHREVEPORT
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State | LA
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Zip | 71105-5312
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Country | US
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Telephone | 318-797-3470
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Fax | 318-797-9956
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Authorized Official
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Title or Position | MD/OWNER
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Name | DR. DALE C FAZIO
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Credential | M.D
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Telephone | 318-797-3470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | PD009
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License Number State | LA
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