Provider Demographics
NPI:1922078765
Name:MASSIMINI, ELIZABETH L (DPM)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:MASSIMINI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 N PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2101
Mailing Address - Country:US
Mailing Address - Phone:610-892-8090
Mailing Address - Fax:610-892-8040
Practice Address - Street 1:1008 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2101
Practice Address - Country:US
Practice Address - Phone:610-892-8090
Practice Address - Fax:610-892-8040
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003395L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01600367Medicaid
T92572Medicare UPIN
PA600367Medicare ID - Type Unspecified
PA01600367Medicaid