Healthcare Provider Details

I. General information

NPI: 1770937419
Provider Name (Legal Business Name): SAMANTHA MASTANDUNO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 12/02/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 MADISON AVE FL 34
NEW YORK NY
10022-1010
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 888-636-7840
  • Fax:
Mailing address:
  • Phone: 609-677-7003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MB11284200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number302377
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: