Provider Demographics
NPI:1053464842
Name:FRACASSO, MARK ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:FRACASSO
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 1:2333 ONTARIO RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009
Mailing Address - Country:US
Mailing Address - Phone:202-420-7008
Mailing Address - Fax:202-332-0541
Practice Address - Street 1:2333 ONTARIO RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-2627
Practice Address - Country:US
Practice Address - Phone:202-420-7008
Practice Address - Fax:202-332-0541
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034665207V00000X
DCMD15297207V00000X
MDD68386207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG012363OtherMEDICARE PTAN
DC581135ZEMBOtherMEDICARE GROUP MEMEBER PTAN
DC052748300Medicaid
VA0101034665OtherMEDICAL LISCENSE
VA0101034665OtherMEDICAL LISCENSE
VA677383Medicare PIN
DC581135ZEMBOtherMEDICARE GROUP MEMEBER PTAN