Provider Demographics
NPI:1124039193
Name:MASON, CHARLES W (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:MASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:920 OLIVER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5702
Practice Address - Country:US
Practice Address - Phone:318-807-4730
Practice Address - Fax:318-812-6450
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA017714208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1347744Medicaid
LA274271YJBUMedicare UPIN
LA1347744Medicaid
LA52812F600Medicare ID - Type Unspecified