Basic Information
| Provider Information | |||||||||
| NPI: | 1659317949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASTER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 WHITE HORSE PIKE | ||||||||
| Address2: | |||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563100042 | ||||||||
| FaxNumber: | 8563100092 | ||||||||
| Practice Location | |||||||||
| Address1: | 1045 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132032730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154724471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | 25MA06269400 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 6917007 | 05 | NJ | MEDICAID |