Provider Demographics
NPI:1912968298
Name:SAMPLE, JASON M (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:SAMPLE
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 1:56-45 MAIN STREET
Mailing Address - Street 2:W-LL300
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5045
Mailing Address - Country:US
Mailing Address - Phone:718-445-0220
Mailing Address - Fax:718-939-1167
Practice Address - Street 1:56-45 MAIN STREET
Practice Address - Street 2:W-LL300
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-445-0220
Practice Address - Fax:718-939-1167
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215514208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02427085Medicaid
H61948Medicare UPIN
NY01055FMedicare PIN
NYH61948Medicare UPIN