Provider Demographics
NPI:1215991005
Name:FAZELI, AMIN (MD)
Entity type:Individual
Prefix:
First Name:AMIN
Middle Name:
Last Name:FAZELI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 MEDICAL CENTER DR
Mailing Address - Street 2:DERMATOLOGY ASSOCIATES OF CNY PLLC
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6613
Mailing Address - Country:US
Mailing Address - Phone:315-663-0100
Mailing Address - Fax:315-663-0052
Practice Address - Street 1:4110 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6613
Practice Address - Country:US
Practice Address - Phone:315-663-0100
Practice Address - Fax:585-663-0052
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236051207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA7948Medicaid
I40590Medicare UPIN
I40590Medicare UPIN