Healthcare Provider Details

I. General information

NPI: 1174795066
Provider Name (Legal Business Name): JEREMIAH ROBERT MASON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E PARRISH AVE BLDG B, STE 101
OWENSBORO KY
42303-1449
US

IV. Provider business mailing address

1926 ARBORO PL
LOUISVILLE KY
40220-3580
US

V. Phone/Fax

Practice location:
  • Phone: 270-683-3232
  • Fax: 270-852-1600
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number03345
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: