Provider Demographics
NPI:1649224817
Name:MASTROSIMONE, MARIA G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:G
Last Name:MASTROSIMONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 HIGHLAND PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620
Mailing Address - Country:US
Mailing Address - Phone:585-461-5091
Mailing Address - Fax:
Practice Address - Street 1:1441 EAST AVE
Practice Address - Street 2:SUITE 107-2
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1665
Practice Address - Country:US
Practice Address - Phone:585-234-4081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400000981OtherMEDICARE PTAN
P010196380OtherEXCELLUS PLANS
NY01728409Medicaid
NYJ400000981OtherMEDICARE PTAN
NYRB1102Medicare ID - Type UnspecifiedGROUP BA0017
CC0087Medicare ID - Type Unspecified
NY01728409Medicaid