Healthcare Provider Details

I. General information

NPI: 1558369298
Provider Name (Legal Business Name): VINCENT W MUSTACIUOLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SEAVIEW AVE SUITE 100
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

501 SEAVIEW AVE SUITE 100
STATEN ISLAND NY
10305-3436
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-0077
  • Fax: 718-667-4103
Mailing address:
  • Phone: 718-667-0077
  • Fax: 718-667-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number198311
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: