Basic Information
| Provider Information | |||||||||
| NPI: | 1104880731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAS | ||||||||
| FirstName: | DASSY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MAS-SLATTERY | ||||||||
| OtherFirstName: | DASSY | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1137 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329021137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219529696 | ||||||||
| FaxNumber: | 3219527937 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 MALABAR RD | ||||||||
| Address2: | |||||||||
| City: | MALABAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329503120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217228435 | ||||||||
| FaxNumber: | 3217228486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 07/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME74007 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 254831300 | 05 | FL | MEDICAID |