Provider Demographics
NPI:1770613440
Name:MASON, EDDY CARL SR
Entity type:Individual
Prefix:MR
First Name:EDDY
Middle Name:CARL
Last Name:MASON
Suffix:SR
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 1:326NCOOPERAVE.
Mailing Address - Street 2:APT#2
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-2921
Mailing Address - Country:US
Mailing Address - Phone:513-769-3910
Mailing Address - Fax:
Practice Address - Street 1:326 N COOPER AVE
Practice Address - Street 2:APT#2
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-2921
Practice Address - Country:US
Practice Address - Phone:513-769-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRM204754374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2454464Medicaid