Individual
MICHAEL VINCENT DEFAZIO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
14546 OLD SAINT AUGUSTINE RD STE 407, JACKSONVILLE, FL 32258-5473
(904) 262-3372
(904) 262-3306
Mailing address
11945 SAN JOSE BLVD STE 300, JACKSONVILLE, FL 32223-1627
(904) 396-1725
(904) 396-4893
Taxonomy
Speciality
Code
Description
License number
State
2086S0122X
Plastic and Reconstructive Surgery Physician
Primary
R6770
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
387059401
—
TX
05
—
387059402
—
TX
01
—
8JM813
BCBS
TX
Enumeration date
04/09/2012
Last updated
08/01/2019
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