Healthcare Provider Details

I. General information

NPI: 1598020174
Provider Name (Legal Business Name): JASON DOUGLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 FRANCISCAN WAY STE 3A
MICHIGAN CITY IN
46360-0033
US

IV. Provider business mailing address

7895 GRAND BLVD
HOBART IN
46342-6665
US

V. Phone/Fax

Practice location:
  • Phone: 219-861-8828
  • Fax: 219-861-8827
Mailing address:
  • Phone: 219-947-1910
  • Fax: 219-947-3117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036150263
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301101431
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: