Healthcare Provider Details

I. General information

NPI: 1194745299
Provider Name (Legal Business Name): THOMAS D MASTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 FLY RD
EAST SYRACUSE NY
13057-9717
US

IV. Provider business mailing address

6620 FLY RD
EAST SYRACUSE NY
13057-9717
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-9390
  • Fax: 315-464-6482
Mailing address:
  • Phone: 315-464-9390
  • Fax: 315-464-6482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number154187
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: