Healthcare Provider Details

I. General information

NPI: 1104816727
Provider Name (Legal Business Name): WILLIAM VAN HORN MASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CARLISLE PL SE
ALBUQUERQUE NM
87108-4371
US

IV. Provider business mailing address

800 CARLISLE PL SE
ALBUQUERQUE NM
87108-4371
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1164
  • Fax:
Mailing address:
  • Phone: 505-265-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number6544
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: