Provider Demographics
NPI:1144277336
Name:DE FAZIO, JOSEPH CHARLES (DC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CHARLES
Last Name:DE FAZIO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 E PARK PL
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2314
Mailing Address - Country:US
Mailing Address - Phone:201-460-1643
Mailing Address - Fax:201-438-7084
Practice Address - Street 1:549 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2701
Practice Address - Country:US
Practice Address - Phone:201-533-1004
Practice Address - Fax:201-533-1008
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC001673111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ455786Medicare ID - Type Unspecified