Provider Demographics
NPI:1184747305
Name:MASIELLO, DOMENICK JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:DOMENICK
Middle Name:JOHN
Last Name:MASIELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:430 OLD SIB RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-2335
Mailing Address - Country:US
Mailing Address - Phone:212-688-4818
Mailing Address - Fax:855-798-2816
Practice Address - Street 1:430 OLD SIB RD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-2335
Practice Address - Country:US
Practice Address - Phone:203-826-3582
Practice Address - Fax:855-798-2816
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167000207Q00000X, 204D00000X
CT000278207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine