Provider Demographics
NPI:1902804347
Name:KOOCH, JASON EVERETT (DO)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:EVERETT
Last Name:KOOCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:115 EILEEN WAY
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-5323
Mailing Address - Country:US
Mailing Address - Phone:516-795-3033
Mailing Address - Fax:516-795-3036
Practice Address - Street 1:115 EILEEN WAY
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-5323
Practice Address - Country:US
Practice Address - Phone:516-795-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013001208100000X
NY3265072081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
50044478OtherKEYSTONE HEALTH CENTRAL
6432850OtherCIGNA HEALTHCARE
2170526OtherMAMSI
2299715000OtherINDEPENDENCE BLUE CROSS
50044478OtherCAPITAL BLUE CROSS
2299715000OtherAMERIHEALTH
397414OtherHEALTH AMERICA/HEALTH ASS
821131OtherFIRST PRIORITY HEALTH
1622793OtherHIGHMARK BLUE SHIELD
2299715000OtherKEYSTONE HEALTH EAST
7466584OtherAETNA PPO
90338OtherGEISINGER HEALTH PLAN
P3356842OtherOXFORD HEALTH PLANS
PA1011608520001Medicaid
2458473OtherUNITED HEALTHCARE
P00230776OtherRAILROAD MEDICARE
PAI09193Medicare UPIN
2170526OtherMAMSI