Provider Demographics
NPI:1285601419
Name:FAZIO, RICHARD ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANTHONY
Last Name:FAZIO
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 1:78 TODT HILL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4528
Mailing Address - Country:US
Mailing Address - Phone:718-448-1122
Mailing Address - Fax:718-448-8318
Practice Address - Street 1:78 TODT HILL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4528
Practice Address - Country:US
Practice Address - Phone:718-448-1122
Practice Address - Fax:718-448-8318
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140259207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00767666Medicaid
NY0023395OtherGHI
NY00767666Medicaid
NYA61288Medicare UPIN