Provider Demographics
NPI:1194791368
Name:SOFFA, JASON IAN (DO)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:IAN
Last Name:SOFFA
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 1:27450 SCHOENHERR RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6683
Mailing Address - Country:US
Mailing Address - Phone:586-582-7550
Mailing Address - Fax:586-582-7515
Practice Address - Street 1:27450 SCHOENHERR RD
Practice Address - Street 2:SUITE 400
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6683
Practice Address - Country:US
Practice Address - Phone:586-582-7550
Practice Address - Fax:586-582-7515
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI53150194353OtherCONTROLLED SUBSTANCE
MI4828059Medicaid
MI5183594Medicaid
I49176Medicare UPIN
MI53150194353OtherCONTROLLED SUBSTANCE
MI5183594Medicaid