Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | MA032378 | NJ |
N | 207ND0900X | Dermatopathologist | MA032378 | NJ |
N | 207NP0225X | Pediatric Dermatologist | MA032378 | NJ |
N | 207NS0135X | Procedural Dermatology | MA032378 | NJ |
NPI | 1255518205 |
---|---|
Provider Name | Alfredo Salvatore Masullo |
First Address | Hackensack, NJ 07601-2256 |
Second Address | Hackensack, NJ 07601-2256 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2008 |
Last Update Date | 28/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C53267 | (02) | NJ |