Provider Demographics
NPI:1154324457
Name:MASTROTA, KATHERINE (OD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:MASTROTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-7838
Mailing Address - Country:US
Mailing Address - Phone:718-646-2200
Mailing Address - Fax:718-646-6623
Practice Address - Street 1:2785 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7838
Practice Address - Country:US
Practice Address - Phone:718-646-2200
Practice Address - Fax:718-646-6623
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0050013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01952758Medicaid
NYC40671Medicare ID - Type Unspecified
NY01952758Medicaid