MEDICARE: DR. DENISE MASTROMONACO D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	05010384	PA
2	174400000X	Specialist	25MB06489100	NJ
3	207N00000X	Dermatology Physician	25MB06489100	NJ

General Provider Information

NPI Number	:	1336399112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENISE MASTROMONACO D.O.

Provider Business Mailing Address
First Line	:	112 WHITE HORSE PIKE
Second Line	:
City	:	HADDON HEIGHTS
State	:	NJ
Zip	:	08035-1908
Country	:	US
Telephone Number	:	856-546-5353
Fax Number	:	856-546-5315

Provider Business Practice Location Address
First Line	:	112 WHITE HORSE PIKE
Second Line	:
City	:	HADDON HEIGHTS
State	:	NJ
Zip	:	08035-1908
Country	:	US
Telephone Number	:	856-546-5353
Fax Number	:	856-546-5315

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2008
Last Update Date	:	09/30/2019

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