Basic Information
| Provider Information | |||||||||
| NPI: | 1033102363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASOLARO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1750 TYSONS BLVD STE 1160 | ||||||||
| Address2: | |||||||||
| City: | TYSONS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221024230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713419450 | ||||||||
| FaxNumber: | 7035215991 | ||||||||
| Practice Location | |||||||||
| Address1: | 1750 TYSONS BLVD STE 1160 | ||||||||
| Address2: | |||||||||
| City: | TYSONS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713419450 | ||||||||
| FaxNumber: | 7035215991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 0101035642 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 6082777 | 05 | VA | MEDICAID |