Provider Demographics
NPI:1295019560
Name:MASTERNICK-BLACK, JANEEN JOY (DO)
Entity Type:Individual
Prefix:DR
First Name:JANEEN
Middle Name:JOY
Last Name:MASTERNICK-BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JANEEN
Other - Middle Name:JOY
Other - Last Name:MASTERNICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1932 NILES CORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1055
Mailing Address - Country:US
Mailing Address - Phone:330-856-5614
Mailing Address - Fax:330-856-5887
Practice Address - Street 1:1932 NILES CORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1055
Practice Address - Country:US
Practice Address - Phone:330-856-5614
Practice Address - Fax:330-856-5887
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34011831208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0124018Medicaid
OHH433720Medicare UPIN