Provider Demographics
NPI:1629179536
Name:JASON, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:JASON
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 1:25411 CABOT RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5520
Mailing Address - Country:US
Mailing Address - Phone:949-364-5119
Mailing Address - Fax:949-364-1265
Practice Address - Street 1:25411 CABOT RD
Practice Address - Street 2:SUITE 112
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5520
Practice Address - Country:US
Practice Address - Phone:949-364-5119
Practice Address - Fax:949-364-1265
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ648387OtherBLUE SHIELD PIN
CAZZZ648387OtherBLUE SHIELD PIN
CAWG37528DMedicare ID - Type UnspecifiedMEDICARE PROVIDER #