Provider Demographics
NPI:1003809625
Name:MASON, RICHARD W (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:MASON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARTIN AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6590
Mailing Address - Country:US
Mailing Address - Phone:630-355-5633
Mailing Address - Fax:630-355-5215
Practice Address - Street 1:1 E COUNTYLINE RD
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-2178
Practice Address - Country:US
Practice Address - Phone:815-786-2722
Practice Address - Fax:815-786-6840
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03682889208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1921614OtherBC/BS
IL036082819Medicaid
F78060Medicare UPIN
ILL67292Medicare ID - Type Unspecified