Provider Demographics
NPI:1043228158
Name:MASSULLO, MARIO GERARD (DO)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:GERARD
Last Name:MASSULLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3160
Mailing Address - Country:US
Mailing Address - Phone:815-936-3200
Mailing Address - Fax:
Practice Address - Street 1:1710 W. COURT ST.
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-936-3200
Practice Address - Fax:815-936-3203
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082059207R00000X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082059Medicaid
F64243Medicare UPIN
IL036082059Medicaid