Healthcare Provider Details

I. General information

NPI: 1861753485
Provider Name (Legal Business Name): JASON MARK HABECK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0925
US

IV. Provider business mailing address

123 HOSPITAL DR STE 1008
WATERTOWN WI
53098-3320
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-9700
  • Fax: 813-558-6187
Mailing address:
  • Phone: 920-206-6500
  • Fax: 920-261-4013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301100883
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301100883
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME130378
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: