Healthcare Provider Details

I. General information

NPI: 1790772770
Provider Name (Legal Business Name): ROBERT A FASOLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 61ST ST W
BRADENTON FL
34209-5527
US

IV. Provider business mailing address

2210 61ST ST W
BRADENTON FL
34209-5527
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-0611
  • Fax: 941-792-0086
Mailing address:
  • Phone: 941-792-0611
  • Fax: 941-792-0086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMEOO35792
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME0035792
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: