Provider Demographics
NPI:1649238403
Name:ANGLE, JASON M (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:ANGLE
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 1:12635 N 42ND ST
Mailing Address - Street 2:LINDA STEIN
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-7601
Mailing Address - Country:US
Mailing Address - Phone:602-494-5500
Mailing Address - Fax:
Practice Address - Street 1:12635 N 42ND ST
Practice Address - Street 2:LINDA STEIN
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7601
Practice Address - Country:US
Practice Address - Phone:602-494-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4795978Medicaid