Healthcare Provider Details

I. General information

NPI: 1689665671
Provider Name (Legal Business Name): MASON EDWARD WHITE II O. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 GEORGE KOSTAS DR
LOGAN WV
25601-3747
US

IV. Provider business mailing address

407 GEORGE KOSTAS DR
LOGAN WV
25601-3747
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-2020
  • Fax: 304-752-5600
Mailing address:
  • Phone: 304-752-2020
  • Fax: 304-752-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0665OD
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0665-IOD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: