Healthcare Provider Details

I. General information

NPI: 1104843747
Provider Name (Legal Business Name): GLENN ALAN MASTEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2101 ELM ST N
FARGO ND
58102-2417
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-3241
  • Fax: 701-451-7827
Mailing address:
  • Phone: 701-232-3241
  • Fax: 701-451-7827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6167
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: