Provider Demographics
NPI:1376598110
Name:MASULLO, LAWRENCE NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:NICHOLAS
Last Name:MASULLO
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 1:36065 SANTA FE AVE BLDG 36065
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5060
Mailing Address - Country:US
Mailing Address - Phone:254-553-1364
Mailing Address - Fax:800-516-3152
Practice Address - Street 1:36065 SANTA FE AVE BLDG 36065
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-553-1364
Practice Address - Fax:800-516-3152
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3014207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G9302Medicare PIN
TXI48292Medicare UPIN