Provider Demographics
NPI:1073527107
Name:MASON, JOHN KIETH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KIETH
Last Name:MASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10885 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1272
Mailing Address - Country:US
Mailing Address - Phone:805-647-7704
Mailing Address - Fax:805-647-7084
Practice Address - Street 1:10885 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1272
Practice Address - Country:US
Practice Address - Phone:805-647-7704
Practice Address - Fax:805-647-7084
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG09185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG9185BMedicare ID - Type Unspecified
CAA58834Medicare UPIN