Provider Demographics
NPI:1710990585
Name:MASTROLE, RICHARD K
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
Last Name:MASTROLE
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 1:1900 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3737
Mailing Address - Country:US
Mailing Address - Phone:954-351-5838
Mailing Address - Fax:954-351-5836
Practice Address - Street 1:1900 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3737
Practice Address - Country:US
Practice Address - Phone:954-351-5838
Practice Address - Fax:954-351-5836
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32864207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038245100Medicaid
FLO60548Medicare UPIN
FL93697YMedicare ID - Type Unspecified