Provider Demographics
NPI:1477081990
Name:FASOLINO, MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FASOLINO
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 1:8 PIKES HL
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5340
Mailing Address - Country:US
Mailing Address - Phone:207-744-6444
Mailing Address - Fax:
Practice Address - Street 1:8 PIKES HL
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5340
Practice Address - Country:US
Practice Address - Phone:207-744-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEDO2951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program