Provider Demographics
NPI:1285688861
Name:MASK, KELAND JEROME (PT)
Entity Type:Individual
Prefix:MR
First Name:KELAND
Middle Name:JEROME
Last Name:MASK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6904 E. RENO AVENUE
Mailing Address - Street 2:
Mailing Address - City:MEDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-2152
Mailing Address - Country:US
Mailing Address - Phone:405-737-5555
Mailing Address - Fax:405-737-5556
Practice Address - Street 1:6904 E. RENO AVENUE
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2152
Practice Address - Country:US
Practice Address - Phone:405-737-5555
Practice Address - Fax:405-737-5556
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1821208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation