1821354325 NPI number — MICHAEL VINCENT DEFAZIO MD

Table of content: MICHAEL VINCENT DEFAZIO MD (NPI 1821354325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821354325 NPI number — MICHAEL VINCENT DEFAZIO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEFAZIO
Provider First Name:
MICHAEL
Provider Middle Name:
VINCENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821354325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11945 SAN JOSE BLVD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-396-1725
Provider Business Mailing Address Fax Number:
904-396-4893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14546 OLD SAINT AUGUSTINE RD STE 407
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-5473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-262-3372
Provider Business Practice Location Address Fax Number:
904-262-3306
Provider Enumeration Date:
04/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  R6770 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8JM813 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 387059402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 387059401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102835600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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