Provider Demographics
NPI:1871679639
Name:MASEL, BRENT ELLIS (M D)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ELLIS
Last Name:MASEL
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650859 DEPT 710
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265
Mailing Address - Country:US
Mailing Address - Phone:409-772-0620
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-5302
Practice Address - Country:US
Practice Address - Phone:409-772-2222
Practice Address - Fax:409-762-9961
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE92992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000EH316Medicaid
TX00115QMedicare ID - Type Unspecified
TXP000EH316Medicaid