Healthcare Provider Details

I. General information

NPI: 1578797825
Provider Name (Legal Business Name): JASON PHILIP VANBATAVIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF UROLOGY
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

1188 STEEL RD
HAVERTOWN PA
19083-3211
US

V. Phone/Fax

Practice location:
  • Phone: 267-608-5467
  • Fax:
Mailing address:
  • Phone: 914-629-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA10755800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberMT208989
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD458362
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: