Provider Demographics
NPI:1760580310
Name:HIATT, JASON MARSHALL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MARSHALL
Last Name:HIATT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4512
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-0512
Mailing Address - Country:US
Mailing Address - Phone:925-934-3536
Mailing Address - Fax:925-934-0672
Practice Address - Street 1:1401 SPANOS CT
Practice Address - Street 2:SUITE 104
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2810
Practice Address - Country:US
Practice Address - Phone:209-525-3150
Practice Address - Fax:209-525-3153
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4350213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43500OtherBLUE SHIELD
CA000E43500Medicaid
CA480033874OtherRAILROAD MEDICARE
CA000E43500Medicaid
CA000E43500Medicare PIN
CA4765730001Medicare NSC