Provider Demographics
NPI:1386698546
Name:DIFAZIO, MICHAEL D (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:DIFAZIO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 RIDGEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-1012
Mailing Address - Country:US
Mailing Address - Phone:973-386-9007
Mailing Address - Fax:973-386-1342
Practice Address - Street 1:34 RIDGEDALE AVE
Practice Address - Street 2:
Practice Address - City:EAST HANOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-1012
Practice Address - Country:US
Practice Address - Phone:973-386-9007
Practice Address - Fax:973-386-1342
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00152800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor