Provider Demographics
NPI:1407067168
Name:MASTERSON, CLINTON JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:JAMES
Last Name:MASTERSON
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5652
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7026
Practice Address - Country:US
Practice Address - Phone:530-541-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234413207P00000X
CO44775207P00000X
CAA100433207P00000X
NV12330207P00000X
TXM7408207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1407067168Medicaid
CA1407067168Medicaid
CA0A1004330Medicare PIN
NV1407067168Medicaid
CA0A1004331Medicare PIN