Provider Demographics
NPI:1730171414
Name:MASON, LARRY MICHAEL (MD)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:MICHAEL
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 1:8401 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:BYRDSTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38549-6031
Mailing Address - Country:US
Mailing Address - Phone:931-864-3187
Mailing Address - Fax:931-864-7102
Practice Address - Street 1:8401 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:BYRDSTOWN
Practice Address - State:TN
Practice Address - Zip Code:38549
Practice Address - Country:US
Practice Address - Phone:931-864-3187
Practice Address - Fax:931-864-7102
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000013950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3190756Medicaid
B04437Medicare UPIN
TN3190756Medicare PIN