Provider Demographics
NPI:1528005659
Name:MASTROSIMONE, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MASTROSIMONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:SIMONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:111 SE 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7617
Mailing Address - Country:US
Mailing Address - Phone:561-737-1080
Mailing Address - Fax:561-737-1533
Practice Address - Street 1:111 SE 23RD AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7617
Practice Address - Country:US
Practice Address - Phone:561-737-1080
Practice Address - Fax:561-737-1533
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0032865174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264158500Medicaid
FL264158500Medicaid
79498Medicare ID - Type Unspecified