Provider Demographics
NPI:1194723577
Name:FAZIO, DALE CARLTON (DPM)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:CARLTON
Last Name:FAZIO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 E 70TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5312
Mailing Address - Country:US
Mailing Address - Phone:318-797-3470
Mailing Address - Fax:318-797-9956
Practice Address - Street 1:1914 E 70TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5312
Practice Address - Country:US
Practice Address - Phone:318-797-3470
Practice Address - Fax:318-797-9956
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD009213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1318451Medicaid
LAT19719Medicare UPIN
LA1318451Medicaid