Provider Demographics
NPI:1568675270
Name:TOOTELL, MASON (MD)
Entity Type:Individual
Prefix:DR
First Name:MASON
Middle Name:
Last Name:TOOTELL
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 1:2 W CRESCENT PARK FL 2
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2111
Mailing Address - Country:US
Mailing Address - Phone:814-723-0407
Mailing Address - Fax:
Practice Address - Street 1:2 W CRESCENT PARK FL 2
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2111
Practice Address - Country:US
Practice Address - Phone:814-723-0407
Practice Address - Fax:814-726-9412
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD431934207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101944610Medicaid
113634U9RMedicare PIN