Basic Information
| Provider Information | |||||||||
| NPI: | 1790105385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFAZIO | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ATWELL RD | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133261301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473652 | ||||||||
| FaxNumber: | 0754765536 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ATWELL RD | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133261301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473652 | ||||||||
| FaxNumber: | 0754765536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2014 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 01625 | MD | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 007247 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.