Healthcare Provider Details

I. General information

NPI: 1801921218
Provider Name (Legal Business Name): HARRIS AVERY MASKET M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 10/21/2024
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SHORELINE HIGHWAY 210A
MILL VALLEY CA
94941
US

IV. Provider business mailing address

5442 BOYD AVE
OAKLAND CA
94618-1115
US

V. Phone/Fax

Practice location:
  • Phone: 415-388-5520
  • Fax: 415-388-5503
Mailing address:
  • Phone: 510-368-2802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberA74623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: