Provider Demographics
NPI:1780662528
Name:JOHN D MAST MD INC
Entity Type:Organization
Organization Name:JOHN D MAST MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-833-3320
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-0986
Mailing Address - Country:US
Mailing Address - Phone:209-339-9036
Mailing Address - Fax:209-339-1901
Practice Address - Street 1:473 W EATON AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376
Practice Address - Country:US
Practice Address - Phone:209-833-3320
Practice Address - Fax:209-835-5929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34146208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G341461Medicaid
A45800Medicare UPIN
CAZZZ27860ZMedicare ID - Type Unspecified