Provider Demographics
NPI:1033102363
Name:CASOLARO, MARIO ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ANTHONY
Last Name:CASOLARO
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 1:1750 TYSONS BLVD STE 1160
Mailing Address - Street 2:
Mailing Address - City:TYSONS
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4230
Mailing Address - Country:US
Mailing Address - Phone:571-341-9450
Mailing Address - Fax:703-521-5991
Practice Address - Street 1:1750 TYSONS BLVD STE 1160
Practice Address - Street 2:
Practice Address - City:TYSONS
Practice Address - State:VA
Practice Address - Zip Code:22102
Practice Address - Country:US
Practice Address - Phone:571-341-9450
Practice Address - Fax:703-521-5991
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035642207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6082777Medicaid
VA507466P78Medicare PIN
VAC89162Medicare UPIN