Provider Demographics
NPI:1205812625
Name:FASULLO, FRANK JOSEPH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:FRANK
Middle Name:JOSEPH
Last Name:FASULLO
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:17047 EL CAMINO REAL
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2652
Mailing Address - Country:US
Mailing Address - Phone:281-415-1972
Mailing Address - Fax:281-486-9904
Practice Address - Street 1:17047 EL CAMINO REAL
Practice Address - Street 2:SUITE 105
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2652
Practice Address - Country:US
Practice Address - Phone:281-415-1972
Practice Address - Fax:281-486-9904
Is Sole Proprietor?:No
Enumeration Date:2005-12-17
Last Update Date:2021-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXJ8532207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140050914Medicaid
TXG14321Medicare UPIN
TX140050914Medicaid