Healthcare Provider Details

I. General information

NPI: 1760444111
Provider Name (Legal Business Name): JASON JOHN SANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 PENNSYLVANIA AVE STE A2ND
FORT WASHINGTON PA
19034-3314
US

IV. Provider business mailing address

400 CHERRY TREE RD
ASTON PA
19014-2406
US

V. Phone/Fax

Practice location:
  • Phone: 215-540-8408
  • Fax: 215-540-8418
Mailing address:
  • Phone: 610-485-6700
  • Fax: 610-485-9540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS012064
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: