Provider Demographics
NPI:1609811314
Name:JACK F MASON MD PROFESSIONAL CORP
Entity Type:Organization
Organization Name:JACK F MASON MD PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-462-0581
Mailing Address - Street 1:555 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5424
Mailing Address - Country:US
Mailing Address - Phone:707-462-0581
Mailing Address - Fax:707-463-0814
Practice Address - Street 1:555 S DORA ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5424
Practice Address - Country:US
Practice Address - Phone:707-462-0581
Practice Address - Fax:707-463-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080990Medicaid
CAGR0080990Medicaid