Provider Demographics
NPI:1255379822
Name:MASTELLONE, SUSAN (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MASTELLONE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12443 PETRILLO DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20777-9567
Mailing Address - Country:US
Mailing Address - Phone:301-854-2120
Mailing Address - Fax:
Practice Address - Street 1:3001 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1233
Practice Address - Country:US
Practice Address - Phone:410-350-3509
Practice Address - Fax:410-350-3511
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH55662207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H23836Medicare UPIN
MD685FMedicare ID - Type Unspecified