Provider Demographics
NPI:1407933393
Name:FASSINO, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:FASSINO
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 1:276 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1808
Mailing Address - Country:US
Mailing Address - Phone:260-563-2126
Mailing Address - Fax:260-563-2120
Practice Address - Street 1:276 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1808
Practice Address - Country:US
Practice Address - Phone:260-563-2126
Practice Address - Fax:260-563-2120
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100385440Medicaid
IN151560J7Medicare PIN
IN100385440Medicaid
INA61881Medicare UPIN
IN223600DMedicare PIN