Provider Demographics
NPI:1255414272
Name:MASON, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:MASON
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 1:900 E SOUTHLAKE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6375
Mailing Address - Country:US
Mailing Address - Phone:817-442-8900
Mailing Address - Fax:817-488-2490
Practice Address - Street 1:900 E SOUTHLAKE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6375
Practice Address - Country:US
Practice Address - Phone:817-442-8900
Practice Address - Fax:817-488-2490
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4330204E00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095081802Medicaid
TX7979112OtherAETNA PIN
TX104535302Medicaid
TX118704100OtherFIRSTCARE PIN
TX1210606OtherFIRSTHEALTH PIN
TX10028366OtherAMERIGROUP PIN
TX124156OtherSUPERIOR PIN
TX8513K0Medicare PIN
TX00817NMedicare PIN
G49002Medicare UPIN