Provider Demographics
NPI:1972593416
Name:MASTEN, KIRK E (DO)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:E
Last Name:MASTEN
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:PO BOX 633260
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3260
Mailing Address - Country:US
Mailing Address - Phone:317-802-6303
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:5734 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7141
Practice Address - Country:US
Practice Address - Phone:260-436-7875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001094207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E36624Medicare UPIN
IN057600XMedicare PIN