Provider Demographics
NPI:1992703573
Name:MASON, TIMOTHY J (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:MASON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9390 E CENTRAL AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2555
Mailing Address - Country:US
Mailing Address - Phone:316-636-2080
Mailing Address - Fax:316-636-2965
Practice Address - Street 1:9390 E CENTRAL AVE
Practice Address - Street 2:STE 101
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2555
Practice Address - Country:US
Practice Address - Phone:316-636-2080
Practice Address - Fax:316-636-2965
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS7304OtherPREFERRED HEALTHE SYSTEMS
KS200000160EMedicaid
KS201552OtherHEALTH PARTNERS OF KS
KS651172OtherBCBS
KS200000160AMedicaid
KS0191040001OtherMEDICARE NSC
KS462314OtherHEALTHWAVE
KS468501OtherCHILDREN'S MERCY/FHP
KSP00467868OtherRR MEDICARE PIN
KS6026440001Medicare NSC
KS651172Medicare PIN
KSU97009Medicare UPIN
KS200000160EMedicaid