Provider Demographics
NPI:1114916343
Name:MASON-RANDALL, SHIRLEY REGINA (MD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:REGINA
Last Name:MASON-RANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2987 BUTLERS BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:CAPE CHARLES
Mailing Address - State:VA
Mailing Address - Zip Code:23310-1429
Mailing Address - Country:US
Mailing Address - Phone:757-331-2022
Mailing Address - Fax:
Practice Address - Street 1:4364 LANKFORD HWY
Practice Address - Street 2:
Practice Address - City:EXMORE
Practice Address - State:VA
Practice Address - Zip Code:23350-2308
Practice Address - Country:US
Practice Address - Phone:757-656-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034675207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5708001Medicaid
050001209Medicare ID - Type Unspecified
E42721Medicare UPIN