Provider Demographics
NPI:1912077843
Name:MASTRACCIO, ALBERT JOSEPH JR (OD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:JOSEPH
Last Name:MASTRACCIO
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:866 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-3530
Mailing Address - Country:US
Mailing Address - Phone:207-324-3295
Mailing Address - Fax:207-324-3295
Practice Address - Street 1:866 MAIN ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-3530
Practice Address - Country:US
Practice Address - Phone:207-324-3295
Practice Address - Fax:207-324-3295
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME037189OtherANTHEM
2162488OtherAETNA
T31672OtherHARVARD PILGRIM
T-31672Medicare UPIN
MA702118Medicare ID - Type Unspecified