Healthcare Provider Details

I. General information

NPI: 1528059391
Provider Name (Legal Business Name): JASON NORBERT SUPPAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 PARADISE RD
ORRVILLE OH
44667-9418
US

IV. Provider business mailing address

6200 PLEASANT AVE STE 3
FAIRFIELD OH
45014-4671
US

V. Phone/Fax

Practice location:
  • Phone: 330-682-6070
  • Fax: 330-684-2822
Mailing address:
  • Phone: 330-682-6070
  • Fax: 330-684-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36-00-3017-S
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36-00-3017-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: