Provider Demographics
NPI:1669807400
Name:MASON, DERRICK JR (RKT)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:MASON
Suffix:JR
Gender:M
Credentials:RKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BLUE GABLE RD
Mailing Address - Street 2:APT. 410
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3004
Mailing Address - Country:US
Mailing Address - Phone:601-896-1983
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1906226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist