Provider Demographics
NPI:1790951325
Name:FASANO, ROSS M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:M
Last Name:FASANO
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 1:1405 CLIFTON RD NE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1062
Mailing Address - Country:US
Mailing Address - Phone:404-785-5532
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:404-778-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-04
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD036088208000000X
GA0725802080P0207X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology