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NPI Code Detail

MEDICARE: JASON S SO DO

MEDICARE: JASON S SO DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician036119919IL
2207Q00000XFamily Medicine Physician63015-21WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11508078643OTHERWIBCBSWI
2SOJASOTHERWIMERCYCARE INSURANCE
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1508078643
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASON S SO DO
Provider Business Mailing Address
First Line : 350 PELLER RD
Second Line :
City : LAKE GENEVA
State : WI
Zip : 53147-4543
Country : US
Telephone Number : 262-245-0221
Fax Number : 262-249-0633
Provider Business Practice Location Address
First Line : 350 PELLER RD
Second Line :
City : LAKE GENEVA
State : WI
Zip : 53147-4543
Country : US
Telephone Number : 262-245-0221
Fax Number : 262-249-0633
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2007
Last Update Date : 08/29/2019

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Directions to “ JASON S SO DO” Practice Location

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