Basic Information
| Provider Information | |||||||||
| NPI: | 1508898776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASON | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7549 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237070549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576863508 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4092 FOXWOOD DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 04/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101052125 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5813671 | 05 | VA | MEDICAID |