Provider Demographics
NPI:1497573182
Name:FUSARO, ANGELO
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:FUSARO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-1775
Mailing Address - Country:US
Mailing Address - Phone:401-430-9923
Mailing Address - Fax:
Practice Address - Street 1:14 CLARA DR
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1973
Practice Address - Country:US
Practice Address - Phone:860-245-0851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0010362081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine