Provider Demographics
NPI:1215166657
Name:MCKELLOP, JASON ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALEXANDER
Last Name:MCKELLOP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 1ST AVE
Mailing Address - Street 2:APT 18 N
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6482
Mailing Address - Country:US
Mailing Address - Phone:202-368-8208
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:LANGONE MEDICAL CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010948732085R0202X
390200000X
NY2745222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program