Provider Demographics
NPI:1508837204
Name:LOTKOWSKI, JASON (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LOTKOWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 DELSEA DR N
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1444
Mailing Address - Country:US
Mailing Address - Phone:856-686-5480
Mailing Address - Fax:856-853-2122
Practice Address - Street 1:617 AUBURN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1620
Practice Address - Country:US
Practice Address - Phone:856-467-7360
Practice Address - Fax:856-467-5959
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07872600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEI38322Medicare UPIN
NJ096919X7MMedicare PIN