Provider Demographics
NPI:1811086382
Name:FAGIOLETTI, ROBERT J (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:FAGIOLETTI
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 1:457 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-3842
Mailing Address - Country:US
Mailing Address - Phone:724-225-7865
Mailing Address - Fax:724-228-1987
Practice Address - Street 1:457 TYLER AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-3842
Practice Address - Country:US
Practice Address - Phone:724-225-7865
Practice Address - Fax:724-228-1987
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD011781E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015559690001Medicaid
PA0015559690001Medicaid
PAB33368Medicare UPIN