Provider Demographics
NPI:1841208840
Name:MASON, DANIEL LUTHER (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LUTHER
Last Name:MASON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 OTAY LAKES RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2443
Mailing Address - Country:US
Mailing Address - Phone:619-267-9900
Mailing Address - Fax:619-267-9910
Practice Address - Street 1:180 OTAY LAKES RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2443
Practice Address - Country:US
Practice Address - Phone:619-267-9900
Practice Address - Fax:619-267-9910
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7989TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0079890Medicaid
CAGV692ZMedicare PIN
CASD0079890Medicaid
T70242Medicare UPIN