Healthcare Provider Details

I. General information

NPI: 1003742172
Provider Name (Legal Business Name): MASON CLARK KOSIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 GARRETT RD STE 1-2
DURHAM NC
27707-3467
US

IV. Provider business mailing address

10829 ROUGEMONT RD
BAHAMA NC
27503-8963
US

V. Phone/Fax

Practice location:
  • Phone: 919-493-1204
  • Fax: 984-250-0156
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP25005
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: