Provider Demographics
NPI:1093120297
Name:MASTAY, ANDREW RICHARD (DPM)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:RICHARD
Last Name:MASTAY
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 1:20905 E 12 MILE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-6501
Mailing Address - Country:US
Mailing Address - Phone:586-772-3500
Mailing Address - Fax:586-772-6540
Practice Address - Street 1:20905 E 12 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-6501
Practice Address - Country:US
Practice Address - Phone:586-772-3500
Practice Address - Fax:586-772-6540
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002523213ES0103X, 213ES0131X, 213E00000X
MIAM002523213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery