Provider Demographics
NPI:1942467469
Name:CADWALLADER, JASON THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:THOMAS
Last Name:CADWALLADER
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 1:30 W MONROE ST
Mailing Address - Street 2:STE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2420
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:2240 E 53RD ST STE B1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3479
Practice Address - Country:US
Practice Address - Phone:317-933-7047
Practice Address - Fax:317-667-1574
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013833A207R00000X
IN01067114A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000685913OtherANTHEM
IN200980050Medicaid
IN000000685913OtherANTHEM