Provider Demographics
NPI:1336399112
Name:MASTROMONACO, DENISE (DO)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:
Last Name:MASTROMONACO
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 1:112 WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1908
Mailing Address - Country:US
Mailing Address - Phone:856-546-5353
Mailing Address - Fax:856-546-5315
Practice Address - Street 1:112 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1908
Practice Address - Country:US
Practice Address - Phone:856-546-5353
Practice Address - Fax:856-546-5315
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05010384174400000X
NJ25MB06489100174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035343070001Medicaid