Provider Demographics
NPI:1093883910
Name:FACCIUTO, MARCELO (MD)
Entity Type:Individual
Prefix:
First Name:MARCELO
Middle Name:
Last Name:FACCIUTO
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 1:1 GUSTAVE L LEVY PL
Mailing Address - Street 2:BOX 1104
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6500
Mailing Address - Country:US
Mailing Address - Phone:212-659-8096
Mailing Address - Fax:212-241-2064
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:12TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-659-8096
Practice Address - Fax:212-241-2064
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226190204F00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02473247Medicaid
NYA400023435Medicare PIN
NY02473247Medicaid