Provider Demographics
NPI:1265448567
Name:MASARACCHIO, MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MASARACCHIO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 73RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-5122
Mailing Address - Country:US
Mailing Address - Phone:718-833-7873
Mailing Address - Fax:718-232-5048
Practice Address - Street 1:7608 15TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2510
Practice Address - Country:US
Practice Address - Phone:718-259-0900
Practice Address - Fax:718-232-5048
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023348-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP6091Medicare ID - Type UnspecifiedMEDICARE PROVIDER