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1568789279 NPI number — MATTHEW JOSEPH FANELLI M.D.

NPI Number: 1568789279
Health Care Provider/Practitioner: MATTHEW JOSEPH FANELLI M.D.

Information about “1568789279” NPI (MATTHEW JOSEPH FANELLI M.D.) exists in 1568789279 in HTML format HTML  |  1568789279 in plain Text format TXT  |  1568789279 in PDF (Portable Document Format) PDF  |  1568789279 in an XML format XML  formats.

NPI Number : 1568789279 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1568789279",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "FANELLI",
    "FirstName": "MATTHEW",
    "MiddleName": "JOSEPH",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "M.D.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "801 YORK ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MANITOWOC",
    "MailingAddressStateName": "WI",
    "MailingAddressPostalCode": "54220-4630",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "920-663-9008",
    "MailingAddressFaxNumber": "920-684-1439",
    "FirstLinePracticeLocationAddress": "66 PARKWAY LN STE 101A",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "FISHERSVILLE",
    "PracticeLocationAddressStateName": "VA",
    "PracticeLocationAddressPostalCode": "22939-2385",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "540-451-2833",
    "PracticeLocationAddressFaxNumber": "540-451-2837",
    "EnumerationDate": "04/21/2010",
    "LastUpdateDate": "08/11/2022",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "207N00000X",
          "TaxonomyName": "Dermatology Physician",
          "LicenseNumber": "71653-20",
          "LicenseNumberStateCode": "WI",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207N00000X",
          "TaxonomyName": "Dermatology Physician",
          "LicenseNumber": "036.137205",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207N00000X",
          "TaxonomyName": "Dermatology Physician",
          "LicenseNumber": "51923",
          "LicenseNumberStateCode": "SC",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207N00000X",
          "TaxonomyName": "Dermatology Physician",
          "LicenseNumber": "0101276020",
          "LicenseNumberStateCode": "VA",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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