Provider Demographics
NPI:1710069943
Name:MASSARO, MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MASSARO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 RAVEN CIR
Mailing Address - Street 2:
Mailing Address - City:CAMDEN WYOMING
Mailing Address - State:DE
Mailing Address - Zip Code:19934-4034
Mailing Address - Country:US
Mailing Address - Phone:215-837-0131
Mailing Address - Fax:
Practice Address - Street 1:640 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3530
Practice Address - Country:US
Practice Address - Phone:302-744-7581
Practice Address - Fax:302-744-7332
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013166207R00000X
DEC2-0013015208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019460330001Medicaid
PA1019460330003Medicaid
PA1019460330002Medicaid
PA2864315000OtherBCBS
PA002114981OtherHIGH MARK BCBS
PAP00472088Medicare PIN
PA113639VYNMedicare PIN