Provider Demographics
NPI:1114968708
Name:MASELLA, PETER A (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:MASELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:620 REISS PL
Mailing Address - Street 2:APT 7G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-8044
Mailing Address - Country:US
Mailing Address - Phone:718-655-9105
Mailing Address - Fax:718-733-3873
Practice Address - Street 1:603 E 187TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6700
Practice Address - Country:US
Practice Address - Phone:718-733-3873
Practice Address - Fax:718-733-3873
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1286712080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A97625Medicare UPIN