Provider Demographics
NPI:1982639621
Name:DAVIS, JASON SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:DAVIS
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 1:35 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2016
Mailing Address - Country:US
Mailing Address - Phone:309-452-1788
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-664-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361010682085U0001X
NMMD2018-09662085R0202X
MA2819292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2613OtherMEDICARE GROUP #
ILG87023Medicare UPIN
IL2613OtherMEDICARE GROUP #