Provider Demographics
NPI:1497740930
Name:MASTERSON, GILBERT A (MD)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:A
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 1:15146 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARNE
Mailing Address - State:MI
Mailing Address - Zip Code:49435-9605
Mailing Address - Country:US
Mailing Address - Phone:616-520-9075
Mailing Address - Fax:616-341-6013
Practice Address - Street 1:15146 16TH AVE
Practice Address - Street 2:
Practice Address - City:MARNE
Practice Address - State:MI
Practice Address - Zip Code:49435-9605
Practice Address - Country:US
Practice Address - Phone:616-520-9075
Practice Address - Fax:616-341-6013
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-1276362084P0800X
MI43010628002084P0800X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4305173Medicaid
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
MI4305173Medicaid
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH0152841Medicaid
MID16083137Medicare PIN
MI4305173Medicaid
OH0152841Medicaid
MIA51995Medicare UPIN