Provider Demographics
NPI:1275575201
Name:FRIED, JASON (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FRIED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6847 N CHESTNUT ST STE 100
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3929
Mailing Address - Country:US
Mailing Address - Phone:330-235-7434
Mailing Address - Fax:330-235-7436
Practice Address - Street 1:6847 N CHESTNUT ST STE 100
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-235-7434
Practice Address - Fax:330-235-7436
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340071882086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2417263Medicaid
P00448931Medicare PIN
H81704Medicare UPIN
4104492Medicare PIN
OH2417263Medicaid
4104494Medicare PIN