Provider Demographics
NPI:1043208242
Name:MOSTONE, EDWARD J (DPM)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:MOSTONE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3337
Mailing Address - Country:US
Mailing Address - Phone:781-396-8737
Mailing Address - Fax:
Practice Address - Street 1:425 SALEM STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-396-8737
Practice Address - Fax:617-547-5367
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA735510207R00000X
MA1793213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0362263Medicaid
MAY70852Medicare PIN
MA0362263Medicaid
MA1127670001Medicare NSC