Healthcare Provider Details

I. General information

NPI: 1013000769
Provider Name (Legal Business Name): JASON M MLNARIK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 TAMIAMI TRL SUITE 1
PORT CHARLOTTE FL
33948-1018
US

IV. Provider business mailing address

1641 TAMIAMI TRL SUITE 1
PORT CHARLOTTE FL
33948-1018
US

V. Phone/Fax

Practice location:
  • Phone: 941-629-6262
  • Fax: 941-629-1782
Mailing address:
  • Phone: 941-629-6262
  • Fax: 941-629-1782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2006022623
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number2006022623
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS14041
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: