Provider Demographics
NPI:1306824719
Name:MASCIELLO, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:MASCIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3105
Mailing Address - Country:US
Mailing Address - Phone:631-669-2555
Mailing Address - Fax:631-669-3051
Practice Address - Street 1:540 UNION BLVD
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3105
Practice Address - Country:US
Practice Address - Phone:631-669-2555
Practice Address - Fax:631-669-3051
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147722207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00888651Medicaid
NYA400029339Medicare PIN
NY41D1513Medicare PIN