Provider Demographics
NPI:1134100530
Name:MASON, JOHN L (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:MASON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 WILDEWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4300
Mailing Address - Country:US
Mailing Address - Phone:803-865-5520
Mailing Address - Fax:803-865-5496
Practice Address - Street 1:141 WILDEWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4300
Practice Address - Country:US
Practice Address - Phone:803-865-5522
Practice Address - Fax:803-865-5496
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1186152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD11869Medicaid
SCDA9757Medicaid
SCDA9816Medicaid
SCU857622326Medicare UPIN
SCU857627430Medicare PIN
SCD11869Medicaid