Provider Demographics
NPI:1649224643
Name:MASTERSON, THOMAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:MASTERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-350-2842
Mailing Address - Fax:510-879-9128
Practice Address - Street 1:9106 PINE VIEW LN
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3229
Practice Address - Country:US
Practice Address - Phone:703-356-2037
Practice Address - Fax:703-734-8987
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2017-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101038350207R00000X
MDD50534207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101038350OtherMEDICAL LICENSE
DCG02313N01Medicare PIN
DCE29989Medicare UPIN