Provider Demographics
NPI:1649212697
Name:MASTRONARDI, DANTE D
Entity Type:Individual
Prefix:
First Name:DANTE
Middle Name:D
Last Name:MASTRONARDI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229-231 STATE ST FL 4
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-2756
Mailing Address - Country:US
Mailing Address - Phone:607-778-1152
Mailing Address - Fax:607-778-1162
Practice Address - Street 1:229-231 STATE ST FL 4
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2756
Practice Address - Country:US
Practice Address - Phone:607-778-1126
Practice Address - Fax:607-778-1164
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF320026363LC1500X
NYF401065363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY050301000145OtherFIDELIS CARE NY
NY0320F320026Medicaid
NYP27256Medicare UPIN
NY050301000145OtherFIDELIS CARE NY