Provider Demographics
NPI:1952062309
Name:MASON, JUSTIN DORE (CRM, PSS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DORE
Last Name:MASON
Suffix:
Gender:M
Credentials:CRM, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 N COAST HWY STE B
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3165
Mailing Address - Country:US
Mailing Address - Phone:541-272-5048
Mailing Address - Fax:541-264-8754
Practice Address - Street 1:145 N COAST HWY STE B
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3165
Practice Address - Country:US
Practice Address - Phone:541-272-5048
Practice Address - Fax:541-264-8754
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-CRM-777175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000105947Medicaid