Provider Demographics
NPI:1801041843
Name:MASTROROCCO, PAUL (DISPENSING OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:MASTROROCCO
Suffix:
Gender:M
Credentials:DISPENSING OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 E MAIN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3171
Mailing Address - Country:US
Mailing Address - Phone:631-475-5030
Mailing Address - Fax:631-475-5037
Practice Address - Street 1:208 ROUTE 112 STE 2
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1013
Practice Address - Country:US
Practice Address - Phone:631-331-0600
Practice Address - Fax:631-331-0809
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5855-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00342952Medicaid
NY00683849Medicaid
NY01934578Medicaid
NY03292940Medicaid