Provider Demographics
NPI:1558369298
Name:MUSTACIUOLO, VINCENT W (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:W
Last Name:MUSTACIUOLO
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 1:501 SEAVIEW AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3436
Mailing Address - Country:US
Mailing Address - Phone:718-667-0077
Mailing Address - Fax:718-667-4103
Practice Address - Street 1:501 SEAVIEW AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-667-0077
Practice Address - Fax:718-667-4103
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198311207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02148929Medicaid
NY02148929Medicaid
NY54B091Medicare ID - Type Unspecified