Provider Demographics
NPI:1457319915
Name:MASON, INGRID (MD)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:MASON
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 1:1020 E 86TH ST
Mailing Address - Street 2:SUITE 24A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1867
Mailing Address - Country:US
Mailing Address - Phone:317-587-0815
Mailing Address - Fax:317-574-7994
Practice Address - Street 1:1020 E 86TH ST
Practice Address - Street 2:SUITE 24A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1867
Practice Address - Country:US
Practice Address - Phone:317-587-0815
Practice Address - Fax:317-574-7994
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01031079174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND94397Medicare UPIN
IN197330Medicare ID - Type Unspecified