Provider Demographics
NPI:1043406812
Name:JUDITH M. MASCOLO, MD, LLC
Entity Type:Organization
Organization Name:JUDITH M. MASCOLO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:MASCOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-233-4600
Mailing Address - Street 1:639 PARK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-3443
Mailing Address - Country:US
Mailing Address - Phone:860-233-4600
Mailing Address - Fax:860-233-4604
Practice Address - Street 1:639 PARK RD
Practice Address - Street 2:STE 100
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-3443
Practice Address - Country:US
Practice Address - Phone:860-233-4600
Practice Address - Fax:860-233-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03786Medicare UPIN