Provider Demographics
NPI:1659995496
Name:MASTRIA, MICHAEL LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOUIS
Last Name:MASTRIA
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 1:1101 LUDLOW ST
Mailing Address - Street 2:APT 803
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:732-299-9919
Mailing Address - Fax:
Practice Address - Street 1:111. S 11TH ST GIBBEN SUITE 8290
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-7407
Practice Address - Fax:215-503-4057
Is Sole Proprietor?:No
Enumeration Date:2020-06-06
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program