Provider Demographics
NPI:1588657985
Name:EBERLY, JASON (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:EBERLY
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 1:325 BLUE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1526
Mailing Address - Country:US
Mailing Address - Phone:610-588-6621
Mailing Address - Fax:610-588-6307
Practice Address - Street 1:325 BLUE VALLEY DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:PA
Practice Address - Zip Code:18013-1526
Practice Address - Country:US
Practice Address - Phone:610-588-6621
Practice Address - Fax:610-588-6307
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004800L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU99910Medicare UPIN