Provider Demographics
NPI:1184036022
Name:MASTROGIACOMO, SANDRA KAY
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
Last Name:MASTROGIACOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 MARKESE AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3254
Mailing Address - Country:US
Mailing Address - Phone:313-585-6072
Mailing Address - Fax:
Practice Address - Street 1:1759 MARKESE AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3254
Practice Address - Country:US
Practice Address - Phone:313-585-6072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor