Provider Demographics
NPI:1255518205
Name:MASULLO, ALFREDO SALVATORE (MD)
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:SALVATORE
Last Name:MASULLO
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 1:120 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2256
Mailing Address - Country:US
Mailing Address - Phone:201-488-0707
Mailing Address - Fax:201-488-0708
Practice Address - Street 1:120 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2256
Practice Address - Country:US
Practice Address - Phone:201-488-0707
Practice Address - Fax:201-488-0708
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA032378207N00000X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC53267Medicare UPIN
NJ103493Medicare PIN