Basic Information
| Provider Information | |||||||||
| NPI: | 1588605794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3431 HARBOR DR | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320847737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048249520 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | HWY 20 WEST | ||||||||
| Address2: | |||||||||
| City: | PALATKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863268300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME36277 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | AM9582607 | 01 | FL | DEA | OTHER |