Provider Demographics
NPI:1588821979
Name:ANDERSON, JASON (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ANDERSON
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 1:1010 CARONDELET DR STE 301
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4823
Mailing Address - Country:US
Mailing Address - Phone:816-943-1111
Mailing Address - Fax:913-780-4834
Practice Address - Street 1:1010 CARONDELET DR STE 301
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4823
Practice Address - Country:US
Practice Address - Phone:816-943-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE337213E00000X
IA000868213E00000X
SD216213E00000X, 213ES0103X
KS12-00473213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1922201227Medicaid
IA1922201227Medicaid
IAI7290Medicare PIN
IA1922201227Medicare PIN