Healthcare Provider Details

I. General information

NPI: 1336149301
Provider Name (Legal Business Name): ALFREDO S MASULLO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 12/19/2007
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:
Mailing address:
  • Phone: 201-488-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMA032378
License Number StateNJ

VIII. Authorized Official

Name: ALFREDO S MASULLO
Title or Position: PRESIDENT
Credential: MD
Phone: 201-488-0707