Provider Demographics
NPI:1215950910
Name:GANZ, JASON C (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:GANZ
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 1:24 RESEARCH WAY
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3487
Mailing Address - Country:US
Mailing Address - Phone:631-444-4666
Mailing Address - Fax:
Practice Address - Street 1:24 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3487
Practice Address - Country:US
Practice Address - Phone:631-444-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60-233290208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00372950OtherMEDICARE RAILROAD
OH7720723OtherAETNA
OH000000503657OtherANTHEM
OH363543OtherWELLCARE MEDICAID
OH000000221046OtherUNISON
OH743421OtherBUCKEYE MEDICAID
OH2595615Medicaid
OHP00372950OtherMEDICARE RAILROAD
I25723Medicare UPIN
OH2595615Medicaid