Healthcare Provider Details

I. General information

NPI: 1124093679
Provider Name (Legal Business Name): MARIO CESARIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 EAST BELLTINE NE STE 201
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

245 STATE ST SE STE 1A
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301091589
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: