Provider Demographics
NPI:1497740930
Name:MASTERSON, GILBERT A (MD)
Entity type:Individual
Prefix:
First Name:GILBERT
Middle Name:A
Last Name:MASTERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 EAST PARIS AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3682
Mailing Address - Country:US
Mailing Address - Phone:616-690-2690
Mailing Address - Fax:616-360-2034
Practice Address - Street 1:1179 EAST PARIS AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3682
Practice Address - Country:US
Practice Address - Phone:616-690-2690
Practice Address - Fax:616-360-2034
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010628002084A0401X, 2084P0800X
OH35-1276362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4305173Medicaid
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
MI4305173Medicaid
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH0152841Medicaid
MID16083137Medicare PIN
MI4305173Medicaid
OH0152841Medicaid
MIA51995Medicare UPIN