Basic Information
| Provider Information | |||||||||
| NPI: | 1053464842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRACASSO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2333 ONTARIO RD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 20009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024207008 | ||||||||
| FaxNumber: | 2023320541 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 ONTARIO RD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200092627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024207008 | ||||||||
| FaxNumber: | 2023320541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
| 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 | 207V00000X | 0101034665 | VA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD15297 | DC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | D68386 | MD | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | G012363 | 01 | DC | MEDICARE PTAN | OTHER | AF1857854 | 01 | VA | DEA | OTHER | 581135ZEMB | 01 | DC | MEDICARE GROUP MEMEBER PTAN | OTHER | 052748300 | 05 | DC | MEDICAID | 0101034665 | 01 | VA | MEDICAL LISCENSE | OTHER |