Provider Demographics
NPI:1033107941
Name:BROKAW, JASON P (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:BROKAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 QUARRY LAKE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3746
Mailing Address - Country:US
Mailing Address - Phone:410-377-8900
Mailing Address - Fax:410-377-3156
Practice Address - Street 1:2700 QUARRY LAKE DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3746
Practice Address - Country:US
Practice Address - Phone:410-377-8900
Practice Address - Fax:410-377-3156
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD616632081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405740600Medicaid
H42416Medicare UPIN