Healthcare Provider Details

I. General information

NPI: 1598857401
Provider Name (Legal Business Name): JASON ELIA MASTOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 JOE V KNOX AVE SUITE F
MOORESVILLE NC
28117-7911
US

IV. Provider business mailing address

206 JOE V KNOX AVE SUITE F
MOORESVILLE NC
28117-7911
US

V. Phone/Fax

Practice location:
  • Phone: 704-662-6500
  • Fax: 704-662-6503
Mailing address:
  • Phone: 704-662-6500
  • Fax: 704-662-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200401095
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: