Healthcare Provider Details

I. General information

NPI: 1083879480
Provider Name (Legal Business Name): JASON TOMASELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 03/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6588
  • Fax:
Mailing address:
  • Phone: 414-649-6588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125052871
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number147048
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number54430
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: