Provider Demographics
NPI:1659990059
Name:MASTROMONACO, MARK PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PETER
Last Name:MASTROMONACO
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 1:468 CADIEUX RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21400 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1566
Practice Address - Country:US
Practice Address - Phone:586-498-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351046408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty