Provider Demographics
NPI:1902898638
Name:MAST, CLARENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:
Last Name:MAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 3J
Mailing Address - Street 2:HOSPITAL DR
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-9706
Mailing Address - Country:US
Mailing Address - Phone:570-265-6300
Mailing Address - Fax:570-268-2807
Practice Address - Street 1:ROUTE 6
Practice Address - Street 2:
Practice Address - City:MESHOPPEN
Practice Address - State:PA
Practice Address - Zip Code:18630
Practice Address - Country:US
Practice Address - Phone:570-833-8300
Practice Address - Fax:570-833-8310
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 0126030E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA677564Medicaid
062990Medicare ID - Type Unspecified
C28658Medicare UPIN