MEDICARE: LOUIS JOHN DIFAZIO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	151941-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	35D611	OTHER	NY	PTAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245231083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOUIS JOHN DIFAZIO M.D.

Provider Business Mailing Address
First Line	:	2371 ARTHUR AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-8113
Country	:	US
Telephone Number	:	718-364-6199
Fax Number	:	718-364-6502

Provider Business Practice Location Address
First Line	:	2371 ARTHUR AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-8113
Country	:	US
Telephone Number	:	718-364-6199
Fax Number	:	718-364-6502

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	11/27/2013

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