Provider Demographics
NPI:1033118336
Name:MASOTTO, MARK NUNZIO (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:NUNZIO
Last Name:MASOTTO
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:PO BOX 14005
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-1405
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:431 S BATAVIA ST
Practice Address - Street 2:STE. 103
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3936
Practice Address - Country:US
Practice Address - Phone:714-538-6731
Practice Address - Fax:714-771-8369
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA612752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A612750Medicaid
300136609OtherRAILROAD MEDICARE
00A612750 159OtherCALOPTIMA
00A612750OtherBLUE SHIELD OF CA
053304CH71589OtherTRAILBLAZER
CA00A612750Medicaid
WA61275BMedicare PIN
00A612750OtherBLUE SHIELD OF CA
00A612750 159OtherCALOPTIMA
WA61275DMedicare PIN