Provider Demographics
NPI:1831379130
Name:MASCIONI, RICHARD EDUARDO (IDC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDUARDO
Last Name:MASCIONI
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SEAL BEACH BLVD
Mailing Address - Street 2:#22
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-5607
Mailing Address - Country:US
Mailing Address - Phone:562-626-7285
Mailing Address - Fax:
Practice Address - Street 1:800 SEAL BEACH BLVD
Practice Address - Street 2:#22
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-5607
Practice Address - Country:US
Practice Address - Phone:562-626-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman