Healthcare Provider Details

I. General information

NPI: 1255518205
Provider Name (Legal Business Name): ALFREDO SALVATORE MASULLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PROSPECT AVE
HACKENSACK NJ
07601-2256
US

IV. Provider business mailing address

120 PROSPECT AVE
HACKENSACK NJ
07601-2256
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-0707
  • Fax: 201-488-0708
Mailing address:
  • Phone: 201-488-0707
  • Fax: 201-488-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMA032378
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMA032378
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberMA032378
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMA032378
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: