Provider Demographics
NPI:1942648027
Name:MASCIOLI, MATTHEW DEAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DEAN
Last Name:MASCIOLI
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 1:602 W ARLINGTON PL
Mailing Address - Street 2:BSMT G
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2685
Mailing Address - Country:US
Mailing Address - Phone:612-747-1976
Mailing Address - Fax:
Practice Address - Street 1:602 W ARLINGTON PL
Practice Address - Street 2:BSMT G
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2685
Practice Address - Country:US
Practice Address - Phone:612-747-1976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036140385208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics