Provider Demographics
NPI:1649469222
Name:MARIO FRACASSA MDPC
Entity type:Organization
Organization Name:MARIO FRACASSA MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-822-3911
Mailing Address - Street 1:732 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4929
Mailing Address - Country:US
Mailing Address - Phone:516-822-3911
Mailing Address - Fax:516-822-3983
Practice Address - Street 1:732 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4929
Practice Address - Country:US
Practice Address - Phone:516-822-3911
Practice Address - Fax:516-822-3983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102963207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEV131Medicare PIN