Provider Demographics
NPI:1174695167
Name:MASTROSTEFANO, PASQUALE ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:PASQUALE
Middle Name:ANTHONY
Last Name:MASTROSTEFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909
Mailing Address - Country:US
Mailing Address - Phone:401-351-1560
Mailing Address - Fax:401-351-1560
Practice Address - Street 1:347 BROADWAY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909
Practice Address - Country:US
Practice Address - Phone:401-351-1560
Practice Address - Fax:401-351-1560
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI3995207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI6066 RIBCOtherBLUE CROSS BLUE SHEILD
RI9000606Medicaid
RI001433OtherBLUE CHIP
RI9000606Medicaid