Provider Demographics
NPI:1578660593
Name:SERPE, JASON L (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:SERPE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RIVERSIDE DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5004
Mailing Address - Country:US
Mailing Address - Phone:815-935-2991
Mailing Address - Fax:815-932-9659
Practice Address - Street 1:400 RIVERSIDE DR STE 2100
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5004
Practice Address - Country:US
Practice Address - Phone:815-935-2991
Practice Address - Fax:815-932-9659
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005003213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL16005003Medicaid
IL4632039OtherBC GROUP #
IL4632039OtherBC GROUP #
ILU85888Medicare UPIN
IL201513Medicare ID - Type UnspecifiedMCD IND # WILL COUNTY
IL201459Medicare ID - Type UnspecifiedMCD IND # KANKAKEE COUNTY