Basic Information
| Provider Information | |||||||||
| NPI: | 1114169372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAZILI | ||||||||
| FirstName: | ANEES | ||||||||
| MiddleName: | AHMED | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2615 CULVER RD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146091716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853365320 | ||||||||
| FaxNumber: | 5853369114 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 CULVER RD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146091716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853365320 | ||||||||
| FaxNumber: | 5853369114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 265847 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 04312492 | 05 | NY | MEDICAID |