Healthcare Provider Details

I. General information

NPI: 1497740930
Provider Name (Legal Business Name): GILBERT A MASTERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 EAST PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-3682
US

IV. Provider business mailing address

1179 EAST PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-3682
US

V. Phone/Fax

Practice location:
  • Phone: 616-690-2690
  • Fax: 616-360-2034
Mailing address:
  • Phone: 616-690-2690
  • Fax: 616-360-2034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number4301062800
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35-127636
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301062800
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: