Provider Demographics
NPI:1508078643
Name:SO, JASON S (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:SO
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 1:350 PELLER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-4543
Mailing Address - Country:US
Mailing Address - Phone:262-245-0221
Mailing Address - Fax:262-249-0633
Practice Address - Street 1:350 PELLER RD
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4543
Practice Address - Country:US
Practice Address - Phone:262-245-0221
Practice Address - Fax:262-249-0633
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119919207Q00000X
WI63015-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508078643OtherBCBSWI
WISOJASOtherMERCYCARE INSURANCE
WI1508078643Medicaid
WI1508078643OtherBCBSWI
WI000054176 - K400168Medicare PIN