Provider Demographics
NPI:1356341622
Name:MASARECH, MARTIN (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MASARECH
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:15 BIRDSALL ST
Practice Address - Street 2:
Practice Address - City:GREENE
Practice Address - State:NY
Practice Address - Zip Code:13778-1057
Practice Address - Country:US
Practice Address - Phone:607-656-4115
Practice Address - Fax:607-656-9553
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00944918Medicaid
NYBB8732Medicare PIN
NY00944918Medicaid