Provider Demographics
NPI:1194745299
Name:MASTEN, THOMAS D (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:MASTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 FLY RD
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9717
Mailing Address - Country:US
Mailing Address - Phone:315-464-9390
Mailing Address - Fax:315-464-6482
Practice Address - Street 1:6620 FLY RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9717
Practice Address - Country:US
Practice Address - Phone:315-464-9390
Practice Address - Fax:315-464-6482
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154187207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00920549Medicaid
NYRA0344Medicare PIN
NY00920549Medicaid