Provider Demographics
NPI:1154704906
Name:RABENO FASOLO, LUCAS (MD)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:RABENO FASOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:305-653-1770
Mailing Address - Fax:786-725-3453
Practice Address - Street 1:20801 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-2103
Practice Address - Country:US
Practice Address - Phone:305-653-1770
Practice Address - Fax:786-725-3453
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264115207R00000X
MA277164207R00000X
FLME152888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA237221597Medicaid