Healthcare Provider Details

I. General information

NPI: 1215950910
Provider Name (Legal Business Name): JASON C GANZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 RESEARCH WAY
EAST SETAUKET NY
11733-3487
US

IV. Provider business mailing address

24 RESEARCH WAY
EAST SETAUKET NY
11733-3487
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-4666
  • Fax:
Mailing address:
  • Phone: 631-444-4666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number60-233290
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number60-233290
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: