Provider Demographics
NPI:1750303079
Name:VAN ITTERSUM, JASON BARRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:BARRETT
Last Name:VAN ITTERSUM
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:6225 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7831
Practice Address - Country:US
Practice Address - Phone:231-798-9500
Practice Address - Fax:231-798-9533
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJV074360207NS0135X
MI4301074360207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4532162Medicaid
MI0706110872OtherMICHIGAN BCBS ID
MI0P29750Medicare ID - Type UnspecifiedMEDICARE GROUP ID
MI4532162Medicaid