Provider Demographics
NPI:1285648477
Name:TATKA, JASON R (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:TATKA
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 1:20800 HARVARD RD
Mailing Address - Street 2:2ND FLR
Mailing Address - City:HIGHLAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6847 N CHESTNUT ST
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:216-286-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020030582080N0001X
PAOS010665L2080N0001X, 208000000X
OH34-012050208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200476730Medicaid
OH2821398Medicaid
147730FFFFMedicare PIN
I16729Medicare UPIN