Provider Demographics
NPI:1578734158
Name:DUJON, JAY EDGAR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:EDGAR
Last Name:DUJON
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 1:1221 SIXTH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2360
Mailing Address - Country:US
Mailing Address - Phone:231-935-2400
Mailing Address - Fax:231-935-2424
Practice Address - Street 1:1221 SIXTH ST STE 300
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2360
Practice Address - Country:US
Practice Address - Phone:231-935-2400
Practice Address - Fax:231-935-2424
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206790208600000X
MI4301086439208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2356461Medicaid
LA348363YH54OtherMEDICARE - PTAN