Healthcare Provider Details

I. General information

NPI: 1154642486
Provider Name (Legal Business Name): MELISSA MASCARO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 OVERLOOK RD
SUMMIT NJ
07901-3570
US

IV. Provider business mailing address

PO BOX 258
HAZLET NJ
07730-0258
US

V. Phone/Fax

Practice location:
  • Phone: 973-798-8793
  • Fax:
Mailing address:
  • Phone: 973-798-8793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number051503
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA08999800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: