Healthcare Provider Details

I. General information

NPI: 1669491569
Provider Name (Legal Business Name): JOSEPH BURTON MASTERNICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 TRAILWOOD DR
BOARDMAN OH
44512-5007
US

IV. Provider business mailing address

P.O. BOX 14290
POLAND OH
44514
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-4568
  • Fax: 330-758-5683
Mailing address:
  • Phone: 330-758-4568
  • Fax: 330-758-5683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.002093
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: