Provider Demographics
NPI:1679920755
Name:MAST, ALEXANDER CLAYTON (DO)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:CLAYTON
Last Name:MAST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1140 S KNOXVILLE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2609
Mailing Address - Country:US
Mailing Address - Phone:419-300-1129
Mailing Address - Fax:419-394-9575
Practice Address - Street 1:1010 HAGER ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2421
Practice Address - Country:US
Practice Address - Phone:419-394-9579
Practice Address - Fax:419-394-9580
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024607208000000X
MI5101022366390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics