Provider Demographics
NPI:1316574940
Name:MASTROIANNI, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MASTROIANNI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-1852
Mailing Address - Country:US
Mailing Address - Phone:413-579-4565
Mailing Address - Fax:
Practice Address - Street 1:19 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2505
Practice Address - Country:US
Practice Address - Phone:413-612-0031
Practice Address - Fax:413-612-0031
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA490237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1598891855Medicaid