Provider Demographics
NPI:1639897267
Name:PRADO, JASON XAVIER
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:XAVIER
Last Name:PRADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11899 RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2735
Mailing Address - Country:US
Mailing Address - Phone:571-239-4883
Mailing Address - Fax:
Practice Address - Street 1:2764 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6277
Practice Address - Country:US
Practice Address - Phone:571-239-4883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL39229208100000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation