Provider Demographics
NPI:1124287958
Name:IDELSON, JASON D (DO)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:D
Last Name:IDELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 1470
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1470
Mailing Address - Country:US
Mailing Address - Phone:516-629-2454
Mailing Address - Fax:516-629-2452
Practice Address - Street 1:100 PORT WASHINGTON BLVD.
Practice Address - Street 2:DEPT. OF EMERGENCY MEDICINE
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1347
Practice Address - Country:US
Practice Address - Phone:516-562-6605
Practice Address - Fax:516-562-6612
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY257869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program