Provider Demographics
NPI:1427346287
Name:MAST, ERIC D (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:D
Last Name:MAST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S. MAIN ST.
Mailing Address - Street 2:SUITE B
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1714
Mailing Address - Country:US
Mailing Address - Phone:303-772-6244
Mailing Address - Fax:303-702-1623
Practice Address - Street 1:205 S. MAIN ST.
Practice Address - Street 2:SUITE B
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1714
Practice Address - Country:US
Practice Address - Phone:303-772-6244
Practice Address - Fax:303-702-1623
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54581207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46125086Medicaid
COC529679Medicare PIN