Basic Information
| Provider Information | |||||||||
| NPI: | 1861470163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTELLER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2240 E 38TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165103688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148254262 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2240 E 38TH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165103688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148254262 | ||||||||
| FaxNumber: | 8148252616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS006889L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.