Individual
MARIO GERARD MASSULLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1710 W. COURT ST., KANKAKEE, IL 60901
(815) 936-3200
(815) 936-3203
Mailing address
1710 W COURT ST, KANKAKEE, IL 60901-3160
(815) 936-3200
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
036082059
IL
207RC0000X
Cardiovascular Disease Physician
Primary
036082059
IL
207RI0011X
Interventional Cardiology Physician
036082059
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036082059
—
IL
Enumeration date
08/04/2006
Last updated
10/27/2021
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