Provider Demographics
NPI:1225177611
Name:MASTOV, RAFAEL (DPT)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:MASTOV
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 98TH ST APT A3
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5970 S JOG RD STE A-1
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6590
Practice Address - Country:US
Practice Address - Phone:561-300-1999
Practice Address - Fax:561-300-1990
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029091225100000X
FLPT35434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT35334OtherFLORIDA PT LICENSE
NY029091OtherLICENSE
NY02924418Medicaid