Provider Demographics
NPI:1902972060
Name:MASTERSON, LEE THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:THOMAS
Last Name:MASTERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1227
Mailing Address - Country:US
Mailing Address - Phone:518-439-7644
Mailing Address - Fax:518-439-0191
Practice Address - Street 1:204 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1227
Practice Address - Country:US
Practice Address - Phone:518-439-7644
Practice Address - Fax:518-439-0191
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX-3627111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY54285CMedicare ID - Type Unspecified