Provider Demographics
NPI:1073617692
Name:HOLBROOK, JASON J (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:HOLBROOK
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 1:1380 UPPER HEMBREE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:770-442-9016
Mailing Address - Fax:770-442-0193
Practice Address - Street 1:1380 UPPER HEMBREE ROAD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-442-9016
Practice Address - Fax:770-442-0193
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA44237207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11BDQQMMedicare PIN
GAH03835Medicare UPIN