Provider Demographics
NPI:1134127020
Name:MASCOLA, TRENT (DO)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:
Last Name:MASCOLA
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:1720 E VENICE AVE FL 2
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-3190
Practice Address - Country:US
Practice Address - Phone:941-483-9730
Practice Address - Fax:941-483-9745
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2194874OtherUNITED HEALTH CARE
FL45193OtherBC/BS GROUP #
FL5307287001OtherCIGNA
FL268092100Medicaid
FLU1841ZMedicare PIN
FL5307287001OtherCIGNA