Provider Demographics
NPI:1790772770
Name:FASOLI, ROBERT A (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:FASOLI
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 1:2210 61ST ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5527
Mailing Address - Country:US
Mailing Address - Phone:941-792-0611
Mailing Address - Fax:941-792-0086
Practice Address - Street 1:2210 61ST ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5527
Practice Address - Country:US
Practice Address - Phone:941-792-0611
Practice Address - Fax:941-792-0086
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMEOO35792207RP1001X
FLME0035792207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD54713Medicare UPIN