MEDICARE: DOMINICK VINCENT MASTRACCO

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	213ES0103X	Foot & Ankle Surgery Podiatrist	36.003968	OH

General Provider Information

NPI Number	:	1376079855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINICK VINCENT MASTRACCO

Provider Business Mailing Address
First Line	:	6227 FRANK AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-8439
Country	:	US
Telephone Number	:	330-324-5015
Fax Number	:

Provider Business Practice Location Address
First Line	:	6227 FRANK AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-8439
Country	:	US
Telephone Number	:	330-244-8989
Fax Number	:

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

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	06/18/2020

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Directions to “ DOMINICK VINCENT MASTRACCO ” Practice Location

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