Provider Demographics
NPI:1659538197
Name:BURRELL, JASON RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RAY
Last Name:BURRELL
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 1:530 PARKMONT CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4889
Mailing Address - Country:US
Mailing Address - Phone:210-573-7515
Mailing Address - Fax:
Practice Address - Street 1:530 PARKMONT CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4889
Practice Address - Country:US
Practice Address - Phone:210-573-7515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67978208000000X
TN55939208D00000X
PAMD465526208D00000X
TXN6201208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659538197Medicaid
WI1659538197Medicaid