Healthcare Provider Details

I. General information

NPI: 1629093786
Provider Name (Legal Business Name): MARIO RICHARD FRAGALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 WICKS LN
MALVERNE NY
11565-2217
US

IV. Provider business mailing address

163 WICKS LN
MALVERNE NY
11565-2217
US

V. Phone/Fax

Practice location:
  • Phone: 516-593-4758
  • Fax:
Mailing address:
  • Phone: 516-593-4758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number104574-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: