Basic Information
| Provider Information | |||||||||
| NPI: | 1780662528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN D MAST MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 986 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952580986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093399036 | ||||||||
| FaxNumber: | 2093391901 | ||||||||
| Practice Location | |||||||||
| Address1: | 473 W EATON AVE | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098333320 | ||||||||
| FaxNumber: | 2098355929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | MAST | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 2098333320 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G34146 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G341461 | 05 | CA | MEDICAID |