Provider Demographics
NPI:1164869699
Name:STACK, JASON TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:TRAVIS
Last Name:STACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3955 INDIAN RIVER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4800
Mailing Address - Country:US
Mailing Address - Phone:772-569-2330
Mailing Address - Fax:772-569-2630
Practice Address - Street 1:3955 INDIAN RIVER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4800
Practice Address - Country:US
Practice Address - Phone:772-569-2330
Practice Address - Fax:772-569-2632
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME135652207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery