Provider Demographics
NPI:1730316456
Name:ROBERTSON, JASON OWEN (MD, MS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:OWEN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVENUE
Mailing Address - Street 2:CRILE BUILDING, 12TH FLOOR
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195
Mailing Address - Country:US
Mailing Address - Phone:216-445-4051
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVENUE
Practice Address - Street 2:CRILE BUILDING, 12TH FLOOR
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195
Practice Address - Country:US
Practice Address - Phone:216-445-4051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009013686208600000X
MI4301109273390200000X
OH351368812086S0120X
FLME131871390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2009013686OtherMISSOURI TEMPORARY LICENSE