Provider Demographics
NPI:1235230079
Name:MASON, MILES H III (MD)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:H
Last Name:MASON
Suffix:III
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:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:770-476-3021
Mailing Address - Fax:770-476-5845
Practice Address - Street 1:3500 MCCLURE BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:770-476-3021
Practice Address - Fax:770-476-5845
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15399207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000178318AMedicaid
GA4031159OtherAETNA
GAD46038Medicare UPIN