Healthcare Provider Details

I. General information

NPI: 1093120297
Provider Name (Legal Business Name): ANDREW RICHARD MASTAY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 05/21/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27799 WEST GRAND BLVD
DETROIT MI
48202
US

IV. Provider business mailing address

20905 E 12 MILE RD STE 100
ROSEVILLE MI
48066-6501
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2181
  • Fax:
Mailing address:
  • Phone: 586-772-3500
  • Fax: 586-772-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: