Provider Demographics
NPI:1114033396
Name:PORT, JASON L (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:PORT
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 1:212 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1554
Mailing Address - Country:US
Mailing Address - Phone:413-567-0885
Mailing Address - Fax:
Practice Address - Street 1:3640 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1145
Practice Address - Country:US
Practice Address - Phone:413-781-9000
Practice Address - Fax:413-781-7988
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1515462085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3154656Medicaid
MAJ16771OtherBLUE CROSS BLUE SHIELD OF MASSACHUSETTS
MAA21431Medicare PIN