Healthcare Provider Details

I. General information

NPI: 1346877719
Provider Name (Legal Business Name): NICHOLAS MASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

2916 PATTEN RD
HIGHLAND PARK IL
60035-6410
US

V. Phone/Fax

Practice location:
  • Phone: 703-347-4146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number70399
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number70399
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: