Healthcare Provider Details

I. General information

NPI: 1649293846
Provider Name (Legal Business Name): MICHAEL FRACASSA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 VENTURE DRIVE
MOUNT VERNON OH
43050-7001
US

IV. Provider business mailing address

PO BOX 27940 3255 E LIVINGSTON AVE
COLUMBUS OH
43227
US

V. Phone/Fax

Practice location:
  • Phone: 740-393-3338
  • Fax: 740-393-1138
Mailing address:
  • Phone: 614-239-0399
  • Fax: 614-239-6374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36002245
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: