Provider Demographics
NPI:1104998251
Name:MASCARO, JIMMY R (DO)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:R
Last Name:MASCARO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E ALTA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-1413
Mailing Address - Country:US
Mailing Address - Phone:641-683-4454
Mailing Address - Fax:641-683-4450
Practice Address - Street 1:312 E ALTA VISTA AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-1413
Practice Address - Country:US
Practice Address - Phone:641-683-4454
Practice Address - Fax:641-683-4450
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA28586OtherBCBS
IA0739672Medicaid
IA28587OtherBCBS OTHER
IAIA01J4OtherUHC
IA28586OtherBCBS
IAI18777Medicare PIN