Provider Demographics
NPI:1669671731
Name:MICHAEL D MASTERSON, MD
Entity Type:Organization
Organization Name:MICHAEL D MASTERSON, MD
Other - Org Name:MICHAEL D MASTERSON, MD, A MEDICAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-496-1360
Mailing Address - Street 1:227 W JANSS RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1848
Mailing Address - Country:US
Mailing Address - Phone:805-496-1360
Mailing Address - Fax:805-496-8270
Practice Address - Street 1:227 W JANSS RD
Practice Address - Street 2:SUITE 280
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1848
Practice Address - Country:US
Practice Address - Phone:805-496-1360
Practice Address - Fax:805-496-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27552207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG27552OtherMEDICAL LICENSE
CAG27552OtherMEDICAL LICENSE
CAW22342Medicare UPIN