Provider Demographics
NPI:1508003971
Name:POTHAST, JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:POTHAST
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 1:18109 PRINCE PHILIP DR
Mailing Address - Street 2:SUITE 155
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1519
Mailing Address - Country:US
Mailing Address - Phone:301-570-7415
Mailing Address - Fax:301-570-7416
Practice Address - Street 1:18109 PRINCE PHILIP DR
Practice Address - Street 2:SUITE 155
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1519
Practice Address - Country:US
Practice Address - Phone:301-570-7415
Practice Address - Fax:301-570-7416
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00784512081S0010X, 2081S0010X
PAMT196031208100000X
PAMD446276208100000X
FLTRN18815390200000X
VA01012571272081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0308871Medicaid
PA102738394Medicaid
PA102738394Medicaid