Provider Demographics
NPI:1396715280
Name:REICHENBERG, JASON S (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:REICHENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 RIO GRANDE ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1137
Mailing Address - Country:US
Mailing Address - Phone:512-324-8960
Mailing Address - Fax:512-324-8962
Practice Address - Street 1:313 EAST 12TH ST
Practice Address - Street 2:SUITE 103 DERMATOLOGY
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-0001
Practice Address - Country:US
Practice Address - Phone:512-324-9650
Practice Address - Fax:512-324-9653
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM4471207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182011004Medicaid
TX8L26838Medicare PIN
TX182011004Medicaid