Provider Demographics
NPI:1588865612
Name:MAST, MOSE
Entity type:Individual
Prefix:
First Name:MOSE
Middle Name:
Last Name:MAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 VIKING DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7316
Mailing Address - Country:US
Mailing Address - Phone:757-304-0686
Mailing Address - Fax:757-340-1393
Practice Address - Street 1:506 VIKING DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7316
Practice Address - Country:US
Practice Address - Phone:757-304-0686
Practice Address - Fax:757-340-1393
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor