Basic Information
| Provider Information | |||||||||
| NPI: | 1366686487 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FASULO | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 N 11TH ST | ||||||||
| Address2: | SUITE P2200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098921192 | ||||||||
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| Practice Location | |||||||||
| Address1: | 755 N 11TH ST | ||||||||
| Address2: | P2200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098921192 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M9273 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | M9273 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.