Provider Demographics
NPI:1649262924
Name:MASTANDREA, JOSEPH ROBERT (DO)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:MASTANDREA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:4441 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2405
Practice Address - Country:US
Practice Address - Phone:937-298-7351
Practice Address - Fax:937-298-9458
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-003760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0792763Medicaid
OH110236077Medicare PIN
OH0792763Medicaid
C03213Medicare UPIN
OH0599703Medicare PIN