Provider Demographics
NPI:1649348343
Name:MASSULLO, MARY-HELENE A (DO)
Entity type:Individual
Prefix:DR
First Name:MARY-HELENE
Middle Name:A
Last Name:MASSULLO
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 1:501 VAN BUREN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-1534
Mailing Address - Country:US
Mailing Address - Phone:419-436-1035
Mailing Address - Fax:419-436-0765
Practice Address - Street 1:501 VAN BUREN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-1534
Practice Address - Country:US
Practice Address - Phone:419-436-1035
Practice Address - Fax:419-436-0765
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004036208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0786252Medicaid
E88982Medicare UPIN
MA0679701Medicare ID - Type Unspecified