Healthcare Provider Details

I. General information

NPI: 1336211770
Provider Name (Legal Business Name): GARY JOSEPH MASTERSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NORTH EOLA RD SUITE K
AURORA IL
60502
US

IV. Provider business mailing address

405 NORTH EOLA RD SUITE K
AURORA IL
60502
US

V. Phone/Fax

Practice location:
  • Phone: 630-820-0505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: