Provider Demographics
NPI:1346432572
Name:DENBO, JASON WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:WILLIAM
Last Name:DENBO
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 1:176 CRESTMERE PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-3202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-672-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-12
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ15872086X0206X
390200000X
MN625062086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343113201 (MDACC)Medicaid
TX8ET732 (MDACC)OtherBCBS
TX387235YKQH (MDACC)Medicare PIN