MEDICARE: DR. ALBERT JOSEPH MASTRACCIO JR. O.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	152W00000X	Optometrist	OPT652	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	037189	OTHER	ME	ANTHEM
2	2162488	OTHER		AETNA
3	T31672	OTHER		HARVARD PILGRIM

General Provider Information

NPI Number	:	1912077843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALBERT JOSEPH MASTRACCIO JR. O.D.

Provider Business Mailing Address
First Line	:	866 MAIN ST
Second Line	:
City	:	SANFORD
State	:	ME
Zip	:	04073-3530
Country	:	US
Telephone Number	:	207-324-3295
Fax Number	:	207-324-3295

Provider Business Practice Location Address
First Line	:	866 MAIN ST
Second Line	:
City	:	SANFORD
State	:	ME
Zip	:	04073-3530
Country	:	US
Telephone Number	:	207-324-3295
Fax Number	:	207-324-3295

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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