Healthcare Provider Details

I. General information

NPI: 1093893877
Provider Name (Legal Business Name): LAWRENCE S. MASKET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 COQUITO WAY
PORTOLA VALLEY CA
94028-7452
US

IV. Provider business mailing address

101 COQUITO WAY
PORTOLA VALLEY CA
94028-7452
US

V. Phone/Fax

Practice location:
  • Phone: 650-854-5170
  • Fax: 650-854-5106
Mailing address:
  • Phone: 650-854-5170
  • Fax: 650-854-5106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG33479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: