Provider Demographics
NPI:1912986977
Name:GLASS, JASON L (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:GLASS
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7666 CHARLOTTE HWY
Practice Address - Street 2:STE 120
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-7000
Practice Address - Country:US
Practice Address - Phone:803-431-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00688207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910356Medicaid
NC5910356Medicaid