Healthcare Provider Details

I. General information

NPI: 1578768644
Provider Name (Legal Business Name): JASON TRYGVE STUBBS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3654 N INVESTMENT DR # 120
FAYETTEVILLE AR
72703-5441
US

IV. Provider business mailing address

3654 N INVESTMENT DR # 120
FAYETTEVILLE AR
72703-5441
US

V. Phone/Fax

Practice location:
  • Phone: 216-904-6596
  • Fax:
Mailing address:
  • Phone: 216-904-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number5101022863
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number5101022863
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number02004173A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: