Provider Demographics
NPI:1588853667
Name:MASTROLIA, RICARDO S (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:S
Last Name:MASTROLIA
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 1:8905 W LINCOLN AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2468
Mailing Address - Country:US
Mailing Address - Phone:414-329-5647
Mailing Address - Fax:414-329-5928
Practice Address - Street 1:8905 W LINCOLN AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2468
Practice Address - Country:US
Practice Address - Phone:414-329-5647
Practice Address - Fax:414-329-5928
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08075900207V00000X, 207VM0101X
WI53071-20207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588853667Medicaid