Basic Information
| Provider Information | |||||||||
| NPI: | 1407067168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTERSON | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435652 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 2170 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961507026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305413420 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 234413 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 44775 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | A100433 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 12330 | NV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M7408 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1407067168 | 05 | NV | MEDICAID | 1407067168 | 05 | CA | MEDICAID |