Healthcare Provider Details

I. General information

NPI: 1710130018
Provider Name (Legal Business Name): JOSEPH B MASTERNICK DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 TRAILWOOD DR
BOARDMAN OH
44512-5007
US

IV. Provider business mailing address

PO BOX 14290
POLAND OH
44514-7290
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 Code208D00000X
TaxonomyGeneral Practice Physician
License Number34-00-2093
License Number StateOH

VIII. Authorized Official

Name: LORETTA BURNICH
Title or Position: OFFICE MANAGER
Credential:
Phone: 330-758-4568