Basic Information
| Provider Information | |||||||||
| NPI: | 1003800525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASON | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1632 STAFFORD SPRINGS PL | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454586033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376080396 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1632 STAFFORD SPRINGS PL | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454586033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376080396 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 36-00-2819M | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | PO3344 | FL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2187888 | 05 | OH | MEDICAID |