Provider Demographics
NPI:1922397116
Name:MASCARO PANKOVA, ANDRES ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:ANTONIO
Last Name:MASCARO PANKOVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:330 CEDAR ST FL 3
Mailing Address - Street 2:DEPT. OF PLASTIC SURGERY
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3218
Mailing Address - Country:US
Mailing Address - Phone:215-421-3494
Mailing Address - Fax:
Practice Address - Street 1:1500 LANSDOWNE AVE
Practice Address - Street 2:DEPT. OF SURGERY
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1291
Practice Address - Country:US
Practice Address - Phone:215-421-3494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA08865700208600000X
PAMT189530208600000X
CA149967208600000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery