Provider Demographics
NPI:1497196455
Name:MASTELLER, MICHAEL ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:MASTELLER
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 1:125 S JEFFERSON ST
Mailing Address - Street 2:UNIT 3205
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-3739
Mailing Address - Country:US
Mailing Address - Phone:219-688-9208
Mailing Address - Fax:
Practice Address - Street 1:1500 S FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1782
Practice Address - Country:US
Practice Address - Phone:773-542-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-07
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141184208600000X
IL125063645208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery