Provider Demographics
NPI:1962043828
Name:MASON, CAMONIE
Entity Type:Individual
Prefix:
First Name:CAMONIE
Middle Name:
Last Name:MASON
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 1:7140 BEDROCK CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3372
Mailing Address - Country:US
Mailing Address - Phone:804-895-3258
Mailing Address - Fax:
Practice Address - Street 1:7140 BEDROCK CIR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-3372
Practice Address - Country:US
Practice Address - Phone:804-895-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000OtherDEPARTMENT OF VA