Provider Demographics
NPI:1508198201
Name:MASON, ROGER ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALAN
Last Name:MASON
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 1:614 N MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:AR
Mailing Address - Zip Code:71671-1904
Mailing Address - Country:US
Mailing Address - Phone:870-466-4400
Mailing Address - Fax:870-466-4556
Practice Address - Street 1:614 N MARTIN ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-1904
Practice Address - Country:US
Practice Address - Phone:870-466-4400
Practice Address - Fax:870-466-4556
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3485208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149615001Medicaid
AR149615001Medicaid