Provider Demographics
NPI:1407098957
Name:BRAZELTON, JASON DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DOUGLAS
Last Name:BRAZELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:DOUGLAS
Other - Last Name:BRAZELTON-HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1348 NE CUSHING DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3876
Mailing Address - Country:US
Mailing Address - Phone:541-382-7696
Mailing Address - Fax:541-389-5723
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175972207ZP0102X
VT042.0014078207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology