Provider Demographics
NPI:1699972174
Name:MASON, JONATHAN KEITH (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KEITH
Last Name:MASON
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:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:MC CLELLANVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29458-0608
Mailing Address - Country:US
Mailing Address - Phone:843-887-3274
Mailing Address - Fax:843-887-3817
Practice Address - Street 1:57 JESSAMINE AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-5837
Practice Address - Country:US
Practice Address - Phone:843-546-8686
Practice Address - Fax:843-546-1353
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40262208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics