Provider Demographics
NPI:1821408931
Name:MASON, BROCK ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:ALLEN
Last Name:MASON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 N THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9022
Mailing Address - Country:US
Mailing Address - Phone:480-209-3565
Mailing Address - Fax:
Practice Address - Street 1:1400 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5906
Practice Address - Country:US
Practice Address - Phone:480-209-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19625207L00000X
NVSL1008208D00000X
AZ0067452083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice