Provider Demographics
NPI:1215078647
Name:POPE, JASON EDWARD (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:POPE
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 1:220 CONCOURSE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8210
Mailing Address - Country:US
Mailing Address - Phone:844-527-7369
Mailing Address - Fax:
Practice Address - Street 1:220 CONCOURSE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8210
Practice Address - Country:US
Practice Address - Phone:844-527-7369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-06-22
Deactivation Date:2018-10-08
Deactivation Code:
Reactivation Date:2018-10-17
Provider Licenses
StateLicense IDTaxonomies
TN41564207L00000X
WV25047207LP2900X
CA114663207LP2900X
CAA114663207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1821509TMedicaid
WV1215078647OtherSELECTNET A HEALTHSMART NETWORK
WV1215078647OtherSTRATOSE
WV1215078647OtherHEALTHNET/TRICARE
WV002700588OtherHIGHMARK BCBS
WV1215078647OtherPEIA
WV$$$$$$$$$-00OtherOH BWC
WV0011253000OtherMEDICAID GROUP
WV1215078647OtherUMWA
CACA132498Medicare PIN
WVWV1811AMedicare PIN
WV1215078647OtherTHE HEALTHPLAN OF OHIO UPPER VALLEY
WV9572314OtherCIGNA
WV3810025260Medicaid