Provider Demographics
NPI:1760680607
Name:FANALE, JOACHIM MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOACHIM
Middle Name:MICHAEL
Last Name:FANALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:M
Other - Last Name:FANALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2115 WISCONSIN AVE NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2265
Mailing Address - Country:US
Mailing Address - Phone:202-444-8232
Mailing Address - Fax:202-444-7752
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-444-8232
Practice Address - Fax:202-444-7752
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0023132202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCD73370Medicare UPIN
DC131591YT2Medicare PIN