Provider Demographics
NPI:1215905203
Name:LARSON, JASON D (DPM)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2159 ROUTE 88 E
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3232
Mailing Address - Country:US
Mailing Address - Phone:732-899-0015
Mailing Address - Fax:732-899-0061
Practice Address - Street 1:2211 ROUTE 88 E
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3229
Practice Address - Country:US
Practice Address - Phone:732-899-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD002476213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00139128OtherRAILROAD
NJP1134870OtherOXFORD
NJ2K5453OtherHEALTHNET
NJ1088552OtherHORIZON NJ HEALTH
NJ9112600Medicaid
NJU73418Medicare UPIN
NJ9112600Medicaid