Provider Demographics
NPI:1578671665
Name:MAST, ALAN L (DPM)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:L
Last Name:MAST
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N JEBAVY DR
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1923
Mailing Address - Country:US
Mailing Address - Phone:231-843-2690
Mailing Address - Fax:231-843-4338
Practice Address - Street 1:333 N JEBAVY DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1923
Practice Address - Country:US
Practice Address - Phone:231-843-2690
Practice Address - Fax:231-843-4338
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001496213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0717580002OtherDME PROVIDER NUMBER
MI2584722Medicaid
MIT86587Medicare UPIN
MI0717580002OtherDME PROVIDER NUMBER