Provider Demographics
NPI:1982645255
Name:MASCOT, LESTER J (MD)
Entity Type:Individual
Prefix:
First Name:LESTER
Middle Name:J
Last Name:MASCOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W BIG BEAVER
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-649-2323
Mailing Address - Fax:248-649-5998
Practice Address - Street 1:14501 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239
Practice Address - Country:US
Practice Address - Phone:313-534-0300
Practice Address - Fax:315-534-6408
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILM049243208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON93670002Medicare ID - Type Unspecified
A76469Medicare UPIN