Provider Demographics
NPI:1770699340
Name:MASON, MARK L (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
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 1:907 SCHNEIDER ST SE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-3774
Mailing Address - Country:US
Mailing Address - Phone:330-499-1494
Mailing Address - Fax:330-499-3744
Practice Address - Street 1:907 SCHNEIDER ST SE
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-3774
Practice Address - Country:US
Practice Address - Phone:330-499-1494
Practice Address - Fax:330-499-3744
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0997917Medicaid
OH0997917Medicaid
OHU52457Medicare UPIN
OH1196470001Medicare NSC