Provider Demographics
NPI:1689762924
Name:MASTALI, MOHAMMAD REZA (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:REZA
Last Name:MASTALI
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 1:105 PARK PLACE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-6870
Mailing Address - Country:US
Mailing Address - Phone:863-419-2156
Mailing Address - Fax:
Practice Address - Street 1:105 PARK PLACE BLVD STE A
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6870
Practice Address - Country:US
Practice Address - Phone:863-419-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 85686207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
205689196OtherIRS/ EIN
FLG69636Medicare UPIN
FLE8376YMedicare ID - Type Unspecified