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General NPI Number Information
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NPI Number | 1518329515
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Entity Type | Individual
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Provider Name | MATTHEW J FASULLO D.O.
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Gender | Male
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Dates
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Enumeration Date | 03/28/2016
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Last Update Date | 04/12/2024
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Provider Practice Location Address
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Address Line | 169 WADSWORTH DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23236-4500
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Country | US
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Telephone | 804-330-4901
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Fax |
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Provider Business Mailing Address
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Address Line | 165 WADSWORTH DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23236-4500
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Country | US
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Telephone | 804-330-4901
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 0102207822
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License Number State | VA
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