Healthcare Provider Details

I. General information

NPI: 1609438282
Provider Name (Legal Business Name): ERIC STEPHEN MASCELLINO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8485 SW 40TH ST STE 102
MIAMI FL
33155-3262
US

IV. Provider business mailing address

8485 SW 40TH ST STE 102
MIAMI FL
33155-3262
US

V. Phone/Fax

Practice location:
  • Phone: 305-551-3412
  • Fax:
Mailing address:
  • Phone: 305-551-3412
  • Fax: 305-551-1945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO4302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: