Provider Demographics
NPI:1013964717
Name:MASCOLI, NICHOLAS MICHAEL III (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS MICHAEL
Middle Name:
Last Name:MASCOLI
Suffix:III
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 1:2000 WASHINGTON ST
Mailing Address - Street 2:SUITE 546
Mailing Address - City:NEWTON LOWER FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1650
Mailing Address - Country:US
Mailing Address - Phone:617-964-5020
Mailing Address - Fax:
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:SUITE 546
Practice Address - City:NEWTON LOWER FALLS
Practice Address - State:MA
Practice Address - Zip Code:02462-1650
Practice Address - Country:US
Practice Address - Phone:617-964-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77443207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
077443OtherTUFTS HEALTH PLAN
MA3123839Medicaid
110083353OtherRAILROAD MEDICARE
J14524OtherBLUE SHIELD
J14524OtherBLUE SHIELD
F78489Medicare UPIN
MA3123839Medicaid