Provider Demographics
NPI:1376122101
Name:MASTROLONARDO, ERIC VAN
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:VAN
Last Name:MASTROLONARDO
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 1:651 S 51ST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1657
Mailing Address - Country:US
Mailing Address - Phone:805-231-5473
Mailing Address - Fax:
Practice Address - Street 1:925 CHESTNUT ST FL 6
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4204
Practice Address - Country:US
Practice Address - Phone:215-955-6784
Practice Address - Fax:215-923-4532
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program