Provider Demographics
NPI:1013204429
Name:MASSARO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MASSARO
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 1:23701 E EAST FORK RD
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-1477
Mailing Address - Country:US
Mailing Address - Phone:626-250-3300
Mailing Address - Fax:
Practice Address - Street 1:1248 E SWANEE LN
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-1848
Practice Address - Country:US
Practice Address - Phone:626-536-7238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator