Provider Demographics
NPI:1902839517
Name:AMBROSE S. MASTO, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:AMBROSE S. MASTO, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-848-8840
Mailing Address - Street 1:3808 W RIVERSIDE DR
Mailing Address - Street 2:400
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:818-848-0439
Practice Address - Street 1:3808 W RIVERSIDE DR
Practice Address - Street 2:400
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:818-848-0439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG12364208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA38638Medicare UPIN