Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204F00000X | Transplant Surgeon | K7283 | TX |
NPI | 1740463090 |
---|---|
Provider Name | Dr. Carlos G Fasola |
First Address | Dallas, TX 75203-1259 |
Second Address | Dallas, TX 75203-1259 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/12/2007 |
Last Update Date | 04/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
040635703 | (05) | TX |
040635704 | (05) | TX |
8DL222 | BLUE CROSS (01) | TX |