Healthcare Provider Details

I. General information

NPI: 1003809625
Provider Name (Legal Business Name): RICHARD W MASON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E COUNTYLINE RD
SANDWICH IL
60548-2178
US

IV. Provider business mailing address

10 MARTIN AVE STE 225
NAPERVILLE IL
60540-6590
US

V. Phone/Fax

Practice location:
  • Phone: 815-786-2722
  • Fax: 815-786-6840
Mailing address:
  • Phone: 630-355-5633
  • Fax: 630-355-5215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number03682889
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: