Provider Demographics
NPI:1689747735
Name:MASON, GARY ROGERS (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROGERS
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 1:11355 PEMBROOKE SQUARE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:301-645-4419
Mailing Address - Fax:301-645-7006
Practice Address - Street 1:11355 PEMBROOKE SQUARE
Practice Address - Street 2:SUITE 108
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603
Practice Address - Country:US
Practice Address - Phone:301-645-4419
Practice Address - Fax:301-645-7006
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020369207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
697M229FMedicare ID - Type Unspecified
C62631Medicare UPIN