Provider Demographics
NPI:1710938170
Name:MAST, DUANE L
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:L
Last Name:MAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4304
Practice Address - Street 1:550 MIRABEAU ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:OH
Practice Address - Zip Code:45123-1617
Practice Address - Country:US
Practice Address - Phone:937-981-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053818M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000316737OtherBCBS FOR MADISON
MA4121723OtherMEDICARE PIN HOCKING
P00063123OtherMEDICARE RR HOCKING
P00088186OtherRAILROAD MEDICARE
000000341542OtherBCBS CIRCLEVILLE
OH0701100Medicaid
000000316738OtherBCBS MADISON
000000315926OtherBCBS
000000319614OtherBLUE CROSS BLUE SHIELD
000000341542OtherBCBS CIRCLEVILLE
A16679Medicare UPIN
MA4121722Medicare PIN
000000319614OtherBLUE CROSS BLUE SHIELD