Provider Demographics
NPI:1558659615
Name:PROSTROLLO, JASON MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:PROSTROLLO
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 1:1835 COUNTY ROAD C W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1352
Mailing Address - Country:US
Mailing Address - Phone:763-785-4300
Mailing Address - Fax:763-785-7779
Practice Address - Street 1:1835 COUNTY ROAD C W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1352
Practice Address - Country:US
Practice Address - Phone:763-785-4300
Practice Address - Fax:763-785-7779
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57872208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics