Healthcare Provider Details

I. General information

NPI: 1891314241
Provider Name (Legal Business Name): MASTRACCO FOOT & ANKLE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6227 FRANK AVE NW
NORTH CANTON OH
44720-8439
US

IV. Provider business mailing address

6227 FRANK AVE NW
NORTH CANTON OH
44720-8439
US

V. Phone/Fax

Practice location:
  • Phone: 330-244-8989
  • Fax:
Mailing address:
  • Phone: 330-244-8989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DOMINICK MASTRACCO
Title or Position: OWNER
Credential: DPM
Phone: 330-244-8989