Provider Demographics
NPI:1851332019
Name:DEFAZIO, ANTHONY J (OD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2401
Mailing Address - Country:US
Mailing Address - Phone:814-371-4020
Mailing Address - Fax:814-371-1930
Practice Address - Street 1:61 BEAVER DR
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2401
Practice Address - Country:US
Practice Address - Phone:814-371-4020
Practice Address - Fax:814-371-1930
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0366780001OtherDMERC
PADE53721OtherPA BLUE SHIELD
PA0366780001Medicare NSC
PAT27632Medicare UPIN
PA410039936Medicare PIN
PA0366780001OtherDMERC