Provider Demographics
NPI:1760444111
Name:SANDERSON, JASON JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:JOHN
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CHERRY TREE RD
Mailing Address - Street 2:
Mailing Address - City:ASTON
Mailing Address - State:PA
Mailing Address - Zip Code:19014-2406
Mailing Address - Country:US
Mailing Address - Phone:610-485-6700
Mailing Address - Fax:610-485-9540
Practice Address - Street 1:515 PENNSYLVANIA AVE STE A2ND
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3314
Practice Address - Country:US
Practice Address - Phone:215-540-8408
Practice Address - Fax:215-540-8418
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031173500001Medicaid
PADT0827OtherRAILROAD MEDICARE PTAN