Provider Demographics
NPI:1396102620
Name:FASCIANO, ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:FASCIANO
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 1:1748 71ST ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-5227
Mailing Address - Country:US
Mailing Address - Phone:347-641-3210
Mailing Address - Fax:866-824-7488
Practice Address - Street 1:1748 71ST ST APT 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-5227
Practice Address - Country:US
Practice Address - Phone:347-641-3210
Practice Address - Fax:866-834-7488
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-17
Last Update Date:2016-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY175805Medicaid