Provider Demographics
NPI:1972556462
Name:DIFAZIO, MARC P (MD)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:P
Last Name:DIFAZIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9715 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 414
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3320
Mailing Address - Country:US
Mailing Address - Phone:301-309-2211
Mailing Address - Fax:
Practice Address - Street 1:9715 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 414
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3320
Practice Address - Country:US
Practice Address - Phone:301-309-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062946174400000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD005139000Medicaid
VA010248221Medicaid