Provider Demographics
NPI:1124125562
Name:MASON, DOUGLAS E (DPM)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:MASON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 ROUTE 146
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3667
Mailing Address - Country:US
Mailing Address - Phone:518-383-0302
Mailing Address - Fax:518-373-2298
Practice Address - Street 1:950 ROUTE 146
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3667
Practice Address - Country:US
Practice Address - Phone:518-383-0302
Practice Address - Fax:518-373-2298
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006379213ES0131X
IL016-004384213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060201289OtherBLUE CROSS BLUE SHIELD
NY03293698Medicaid
NYN006379OtherLICENSE
IL0060201289OtherBLUE CROSS BLUE SHIELD
ILU18846Medicare UPIN
IL4456080001Medicare NSC
NYJ900087213Medicare PIN