Provider Demographics
NPI:1790854537
Name:LONG, MASON HOYT
Entity Type:Individual
Prefix:DR
First Name:MASON
Middle Name:HOYT
Last Name:LONG
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 1:301 HEALTH PARK BLVD STE 325
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5771
Mailing Address - Country:US
Mailing Address - Phone:904-824-6164
Mailing Address - Fax:904-824-0365
Practice Address - Street 1:301 HEALTH PARK BLVD STE 325
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5771
Practice Address - Country:US
Practice Address - Phone:904-824-6164
Practice Address - Fax:904-824-0365
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038939100Medicaid
FL08803Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FLE22623Medicare UPIN