Provider Demographics
NPI:1710983440
Name:MASON, JOE TODD (MSPT)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:TODD
Last Name:MASON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:J
Other - Middle Name:TODD
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSPT
Mailing Address - Street 1:2235 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-5024
Mailing Address - Country:US
Mailing Address - Phone:270-781-1151
Mailing Address - Fax:270-781-5990
Practice Address - Street 1:2235 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-5024
Practice Address - Country:US
Practice Address - Phone:270-781-1151
Practice Address - Fax:270-781-5990
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000200994OtherANTHEM
5790649OtherAETNA
KY87000527Medicaid
KY000000200994OtherANTHEM
KY00394005Medicare PIN
578498Medicare UPIN