Basic Information
Provider Information
NPI: 1003800525
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MASON
FirstName: PETER
MiddleName: H
NamePrefix:  
NameSuffix:  
Credential: DPM
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1632 STAFFORD SPRINGS PL
Address2:  
City: DAYTON
State: OH
PostalCode: 454586033
CountryCode: US
TelephoneNumber: 9376080396
FaxNumber:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
213ES0103XPO3344FLN Podiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
213ES0103X36-00-2819MOHY Podiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery

ID Information
IDTypeStateIssuerDescription
218788805OH MEDICAID


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