Provider Demographics
NPI:1003848979
Name:MASON, KELLY (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8065
Mailing Address - Country:US
Mailing Address - Phone:810-606-5000
Mailing Address - Fax:
Practice Address - Street 1:1701 BALDWIN AVE STE 102
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1168
Practice Address - Country:US
Practice Address - Phone:248-334-4962
Practice Address - Fax:810-733-1632
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4769584Medicaid