Provider Demographics
NPI:1649726316
Name:JASON GREEN DO PA
Entity type:Organization
Organization Name:JASON GREEN DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-481-0650
Mailing Address - Street 1:260 SW NATURA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-3026
Mailing Address - Country:US
Mailing Address - Phone:954-481-0650
Mailing Address - Fax:954-481-0651
Practice Address - Street 1:260 SW NATURA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-3026
Practice Address - Country:US
Practice Address - Phone:954-481-0650
Practice Address - Fax:954-481-0651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 88871261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16272XMedicare PIN