Provider Demographics
NPI:1104843747
Name:MASTEL, GLENN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ALAN
Last Name:MASTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2601 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-6704
Mailing Address - Country:US
Mailing Address - Phone:701-234-2900
Mailing Address - Fax:701-234-2996
Practice Address - Street 1:2601 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-6704
Practice Address - Country:US
Practice Address - Phone:701-234-2900
Practice Address - Fax:701-234-2996
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND6167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN11582Medicare PIN
D94202Medicare UPIN