Provider Demographics
NPI:1811488646
Name:MAST, JOHN FOX (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:FOX
Last Name:MAST
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 1:1325 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1449
Mailing Address - Country:US
Mailing Address - Phone:630-859-2222
Mailing Address - Fax:
Practice Address - Street 1:1325 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1449
Practice Address - Country:US
Practice Address - Phone:630-859-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036156608208M00000X, 207Q00000X
IL125072449390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program