Provider Demographics
NPI:1942417134
Name:OLIPHANT, JASON LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:LEE
Last Name:OLIPHANT
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 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8551
Mailing Address - Fax:901-260-8590
Practice Address - Street 1:1211 UNION AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6638
Practice Address - Country:US
Practice Address - Phone:901-260-8551
Practice Address - Fax:901-260-8590
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088440208600000X
TN47275208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523676Medicaid
TN103I020868Medicare PIN