Provider Demographics
NPI:1215921184
Name:MASCOVICH, PAUL RICHARD (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:RICHARD
Last Name:MASCOVICH
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 1:322 JACQUELYN LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-5300
Mailing Address - Country:US
Mailing Address - Phone:970-778-5810
Mailing Address - Fax:
Practice Address - Street 1:322 JACQUELYN LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5300
Practice Address - Country:US
Practice Address - Phone:970-778-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG339502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A45733Medicare UPIN
COC805301Medicare PIN