Provider Demographics
NPI:1184738528
Name:JASPER, TRAVAN K (MD)
Entity type:Individual
Prefix:DR
First Name:TRAVAN
Middle Name:K
Last Name:JASPER
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 1:5661 BUNKY WAY
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3338
Mailing Address - Country:US
Mailing Address - Phone:770-652-7341
Mailing Address - Fax:770-396-9860
Practice Address - Street 1:5661 BUNKY WAY
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-3338
Practice Address - Country:US
Practice Address - Phone:770-652-7341
Practice Address - Fax:770-396-9860
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045506207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000794945EMedicaid
GA000794945FMedicaid
GA000794945CMedicaid
GA000794945DMedicaid
GA93BDNPWMedicare ID - Type UnspecifiedMEDICARE PKCD
GAH01153Medicare UPIN