Provider Demographics
NPI:1588832539
Name:STANSBERRY, JASON BRENT (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BRENT
Last Name:STANSBERRY
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 1:2501 N ORANGE AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4674
Mailing Address - Country:US
Mailing Address - Phone:407-303-3638
Mailing Address - Fax:407-303-2882
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-303-7283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1821207R00000X
CO46515207R00000X
FLME104258207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005479300Medicaid
FLME104258OtherMEDICAL LICENSE
FL005479300Medicaid