Healthcare Provider Details

I. General information

NPI: 1871515858
Provider Name (Legal Business Name): TONY MICHAEL MASUCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 RIDGEWOOD ROAD
SPRINGFIELD VT
05156-2003
US

IV. Provider business mailing address

868 BIXBY ROAD
EAST WALLINGFORD VT
05742-9640
US

V. Phone/Fax

Practice location:
  • Phone: 802-885-7691
  • Fax: 802-885-7698
Mailing address:
  • Phone: 802-259-3490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0420009122
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: