Provider Demographics
NPI:1881091882
Name:MASTRANGELO, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MASTRANGELO
Suffix:
Gender:M
Credentials:
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 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-989-3801
Mailing Address - Fax:440-960-0264
Practice Address - Street 1:1120 E BROAD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6306
Practice Address - Country:US
Practice Address - Phone:440-365-2600
Practice Address - Fax:440-366-5543
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50004167363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OH9389631Medicare PIN
OHH430400Medicare PIN