Provider Demographics
NPI:1750787263
Name:MASON, RUSTY JR (CDL)
Entity type:Individual
Prefix:
First Name:RUSTY
Middle Name:
Last Name:MASON
Suffix:JR
Gender:M
Credentials:CDL
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 471353
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20753-1353
Mailing Address - Country:US
Mailing Address - Phone:202-971-6760
Mailing Address - Fax:
Practice Address - Street 1:2001 BURGESS PL
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-1200
Practice Address - Country:US
Practice Address - Phone:202-971-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102X00000X, 172V00000X
MDM250751019101172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No172V00000XOther Service ProvidersCommunity Health Worker