Provider Demographics
NPI:1649293846
Name:FRACASSA, MICHAEL (DPM)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:FRACASSA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27940
Mailing Address - Street 2:3255 E LIVINGSTON AVE
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227
Mailing Address - Country:US
Mailing Address - Phone:614-239-0399
Mailing Address - Fax:614-239-6374
Practice Address - Street 1:1641 VENTURE DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-7001
Practice Address - Country:US
Practice Address - Phone:740-393-3338
Practice Address - Fax:740-393-1138
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002245213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0560147Medicaid
OH0560147Medicaid
T80772Medicare UPIN