Provider Demographics
NPI:1720083892
Name:MASIELLO, MATTHEW G (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:MASIELLO
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:60 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2205
Practice Address - Country:US
Practice Address - Phone:978-466-2257
Practice Address - Fax:978-466-2291
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048546L208000000X
MA58679208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001395041Medicaid
PA001395041Medicaid