Provider Demographics
NPI:1043378367
Name:CARMINE R. MASTROLIA, MD
Entity type:Organization
Organization Name:CARMINE R. MASTROLIA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MASTROLIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-363-9214
Mailing Address - Street 1:240 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2148
Mailing Address - Country:US
Mailing Address - Phone:315-363-9214
Mailing Address - Fax:315-361-4968
Practice Address - Street 1:240 BROAD ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2148
Practice Address - Country:US
Practice Address - Phone:315-363-9214
Practice Address - Fax:315-361-4968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2013-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY145216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03104698Medicaid