Provider Demographics
NPI:1508263120
Name:MARK L MASON OD., LLC
Entity Type:Organization
Organization Name:MARK L MASON OD., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLERICAL
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-499-1494
Mailing Address - Street 1:907 SCHNEIDER ST SE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-3774
Mailing Address - Country:US
Mailing Address - Phone:330-499-1494
Mailing Address - Fax:330-499-3744
Practice Address - Street 1:907 SCHNEIDER ST SE
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-3774
Practice Address - Country:US
Practice Address - Phone:330-499-1494
Practice Address - Fax:330-499-3744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4574305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0997917Medicaid
0770561Medicare PIN
OH1196470001Medicare NSC
OH0997917Medicaid