Provider Demographics
NPI:1417022906
Name:MASTROLY, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MASTROLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 RT.35
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719
Mailing Address - Country:US
Mailing Address - Phone:732-449-9503
Mailing Address - Fax:
Practice Address - Street 1:1933 STATE ROUTE 35
Practice Address - Street 2:SUITE 120
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3502
Practice Address - Country:US
Practice Address - Phone:732-449-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3395156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0772820001Medicare NSC