Provider Demographics
NPI:1497810378
Name:LEE-LLACER, JASON M (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:LEE-LLACER
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:PO BOX 64916
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4916
Mailing Address - Country:US
Mailing Address - Phone:443-481-6467
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2001 MEDICAL PKWY
Practice Address - Street 2:ACUTE CARE PAVILION
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3280
Practice Address - Country:US
Practice Address - Phone:443-481-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
206362OtherJHHC
0042OtherCAREFIRST
89550101OtherCAREFIRST
145724700OtherDEPT. OF LABOR
263508OtherKAISER
1503640OtherAETNA HMO
318699OtherAMERIGROUP
MD412132500Medicaid
7132906OtherAETNA PPO
MD412132500Medicaid
P00420176Medicare PIN