Healthcare Provider Details

I. General information

NPI: 1114968708
Provider Name (Legal Business Name): PETER A MASELLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E 187TH ST
BRONX NY
10458-6700
US

IV. Provider business mailing address

620 REISS PL APT 7G
BRONX NY
10467-8044
US

V. Phone/Fax

Practice location:
  • Phone: 718-733-3873
  • Fax: 718-733-3873
Mailing address:
  • Phone: 718-655-9105
  • Fax: 718-733-3873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number128671
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: