Provider Demographics
NPI:1972516482
Name:FUSCO, MICHAEL STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:FUSCO
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 1:25 S REGENT ST
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-3512
Mailing Address - Country:US
Mailing Address - Phone:914-939-1922
Mailing Address - Fax:914-939-5498
Practice Address - Street 1:25 S REGENT ST
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-3512
Practice Address - Country:US
Practice Address - Phone:914-939-1922
Practice Address - Fax:914-939-5498
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194064207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY194064OtherLICENSE
CT001329813Medicaid
CT032981OtherCT LICENSE
NYF69496Medicare UPIN
CT001329813Medicaid
CT001329813Medicaid