Healthcare Provider Details

I. General information

NPI: 1699972174
Provider Name (Legal Business Name): JONATHAN KEITH MASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 JESSAMINE AVE
GEORGETOWN SC
29440-5837
US

IV. Provider business mailing address

PO BOX 608
MC CLELLANVILLE SC
29458-0608
US

V. Phone/Fax

Practice location:
  • Phone: 843-546-8686
  • Fax: 843-546-1353
Mailing address:
  • Phone: 843-887-3274
  • Fax: 843-887-3817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40262
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: