Provider Demographics
NPI:1770847139
Name:HOGABOAM, JASON PORTER (DO)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:PORTER
Last Name:HOGABOAM
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 1:761 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1643
Mailing Address - Country:US
Mailing Address - Phone:509-264-1814
Mailing Address - Fax:
Practice Address - Street 1:20599 MACK AVE
Practice Address - Street 2:GROSSE POINTE MEDPOST URGENT CARE
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1656
Practice Address - Country:US
Practice Address - Phone:517-279-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-01
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA26570059OtherMEDICARE ID