Provider Demographics
NPI:1972664522
Name:GRASSO, MARIO LUCIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:LUCIO
Last Name:GRASSO
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 1:31 WARD PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2529
Mailing Address - Country:US
Mailing Address - Phone:973-856-1934
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:1 MALONEY BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186316207L00000X
NJ25MA08550900207L00000X
NY251884-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology