Provider Demographics
NPI:1619934668
Name:MASON, THEODORE P (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:P
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 1:100 WASON AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107
Mailing Address - Country:US
Mailing Address - Phone:413-732-7426
Mailing Address - Fax:413-734-2371
Practice Address - Street 1:100 WASON AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:413-732-7426
Practice Address - Fax:413-734-2371
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213321207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0173631Medicaid
MA0173631Medicaid
H55228Medicare UPIN