Healthcare Provider Details

I. General information

NPI: 1902856859
Provider Name (Legal Business Name): JASON RETER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LE FEVRE RD
STERLING IL
61081-1278
US

IV. Provider business mailing address

100 E LE FEVRE RD
STERLING IL
61081-1278
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-0400
  • Fax: 815-625-6728
Mailing address:
  • Phone: 815-625-0400
  • Fax: 815-625-6728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036103279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: