Provider Demographics
NPI:1902039159
Name:MASTRO, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MASTRO
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 1:1524 CULVER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-4241
Mailing Address - Country:US
Mailing Address - Phone:585-288-7555
Mailing Address - Fax:585-288-8998
Practice Address - Street 1:1524 CULVER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-4241
Practice Address - Country:US
Practice Address - Phone:585-288-7555
Practice Address - Fax:585-288-8998
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC6690-1156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter