Healthcare Provider Details

I. General information

NPI: 1396770202
Provider Name (Legal Business Name): JASON BADILLO P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15225 SHADY GROVE RD SUITE 201
ROCKVILLE MD
20850-3254
US

IV. Provider business mailing address

15225 SHADY GROVE RD SUITE 201
ROCKVILLE MD
20850-3254
US

V. Phone/Fax

Practice location:
  • Phone: 301-947-2415
  • Fax: 240-632-0164
Mailing address:
  • Phone: 301-947-2415
  • Fax: 240-632-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002834
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: