Healthcare Provider Details

I. General information

NPI: 1922397116
Provider Name (Legal Business Name): ANDRES ANTONIO MASCARO PANKOVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LANSDOWNE AVE DEPT. OF SURGERY
DARBY PA
19023-1291
US

IV. Provider business mailing address

330 CEDAR ST FL 3 DEPT. OF PLASTIC SURGERY
NEW HAVEN CT
06510-3218
US

V. Phone/Fax

Practice location:
  • Phone: 215-421-3494
  • Fax:
Mailing address:
  • Phone: 215-421-3494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number149967
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA08865700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT189530
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number149967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: