MEDICARE: DR. MOHAMMAD REZA MASTALI M.D.

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	207RG0100X	Gastroenterology Physician	ME 85686	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689762924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOHAMMAD REZA MASTALI M.D.

Provider Business Mailing Address
First Line	:	105 PARK PLACE BLVD STE A
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-6870
Country	:	US
Telephone Number	:	863-419-2156
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 PARK PLACE BLVD STE A
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-6870
Country	:	US
Telephone Number	:	863-419-2156
Fax Number	:

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	12/05/2024

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