Provider Demographics
NPI:1205829686
Name:FOGLIETTI, MARK ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:FOGLIETTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22901 MILLCREEK BLVD
Mailing Address - Street 2:SUITE 145
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5728
Mailing Address - Country:US
Mailing Address - Phone:216-292-6800
Mailing Address - Fax:216-292-7775
Practice Address - Street 1:22901 MILLCREEK BLVD
Practice Address - Street 2:SUITE 145
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5728
Practice Address - Country:US
Practice Address - Phone:216-292-6800
Practice Address - Fax:216-292-7775
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003551F208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0550498Medicaid
OH0654993Medicare PIN
OH0654995Medicare PIN
OH0550498Medicaid