Provider Demographics
NPI:1760421150
Name:MASTO, AMBROSE S (MD)
Entity Type:Individual
Prefix:
First Name:AMBROSE
Middle Name:S
Last Name:MASTO
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 1:3808 W RIVERSIDE DR
Mailing Address - Street 2:STE#400
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4325
Mailing Address - Country:US
Mailing Address - Phone:818-848-8840
Mailing Address - Fax:
Practice Address - Street 1:3808 W RIVERSIDE DR
Practice Address - Street 2:STE#400
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4325
Practice Address - Country:US
Practice Address - Phone:818-848-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG12964208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA38638Medicare UPIN