Provider Demographics
NPI:1154351823
Name:FAROQUI, FAZAL G (DO)
Entity type:Individual
Prefix:
First Name:FAZAL
Middle Name:G
Last Name:FAROQUI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E ROE BLVD
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2631
Mailing Address - Country:US
Mailing Address - Phone:631-475-3900
Mailing Address - Fax:631-475-5606
Practice Address - Street 1:1 E ROE BLVD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2631
Practice Address - Country:US
Practice Address - Phone:631-475-3900
Practice Address - Fax:631-475-5606
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239825207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02772190Medicaid
NY245B1OtherBCBS
NY250SLEK261Medicare PIN
NYP00460189Medicare PIN
NY245B1OtherBCBS