Provider Demographics
NPI:1720055387
Name:MASTROGIACOMO, ANTHONY MARC (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:MARC
Last Name:MASTROGIACOMO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22245 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1639
Mailing Address - Country:US
Mailing Address - Phone:248-486-8886
Mailing Address - Fax:248-486-8887
Practice Address - Street 1:22245 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1639
Practice Address - Country:US
Practice Address - Phone:248-486-8886
Practice Address - Fax:248-486-8887
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM001831213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619433Medicaid
MI4619433Medicaid
MI01794790Medicare PIN
MI01794790Medicare ID - Type Unspecified
MI5126840001Medicare NSC