Provider Demographics
NPI:1982686564
Name:MASON, MICHAEL LLOYD (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LLOYD
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:PO BOX 430
Mailing Address - Street 2:25 CROSS ST
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-0430
Mailing Address - Country:US
Mailing Address - Phone:912-373-2516
Mailing Address - Fax:912-379-0755
Practice Address - Street 1:25 CROSS ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6427
Practice Address - Country:US
Practice Address - Phone:912-375-2516
Practice Address - Fax:912-379-0755
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000687761AMedicaid
GA000687761AMedicaid
GA41ZCCVHMedicare ID - Type Unspecified
GA4795340001Medicare NSC