Provider Demographics
NPI:1093274243
Name:RAU, MASON WADE (MD)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:WADE
Last Name:RAU
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-647-8511
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:2647 S SAINT ELIZABETH BLVD STE 219
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5020
Practice Address - Country:US
Practice Address - Phone:225-647-8511
Practice Address - Fax:225-644-8358
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA330991207R00000X
LA312943207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2494970Medicaid