Healthcare Provider Details

I. General information

NPI: 1750787263
Provider Name (Legal Business Name): RUSTY MASON JR. CDL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 BURGESS PL
FORESTVILLE MD
20747-1200
US

IV. Provider business mailing address

PO BOX 471353
DISTRICT HEIGHTS MD
20753-1353
US

V. Phone/Fax

Practice location:
  • Phone: 202-971-6760
  • Fax:
Mailing address:
  • Phone: 202-971-6760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberM250751019101
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: