Provider Demographics
NPI:1629093786
Name:FRAGALA, MARIO RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:RICHARD
Last Name:FRAGALA
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 1:163 WICKS LN
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-2217
Mailing Address - Country:US
Mailing Address - Phone:516-593-4758
Mailing Address - Fax:
Practice Address - Street 1:163 WICKS LN
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-2217
Practice Address - Country:US
Practice Address - Phone:516-593-4758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104574-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry