Provider Demographics
NPI:1215997069
Name:ALLEN, JASON C (DPM)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:C
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:CORNERSTONE
Other - Middle Name:
Other - Last Name:PODIATRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1701 N STOCKTON HILL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6600
Mailing Address - Country:US
Mailing Address - Phone:928-753-4500
Mailing Address - Fax:
Practice Address - Street 1:1701 N STOCKTON HILL RD
Practice Address - Street 2:SUITE D
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6600
Practice Address - Country:US
Practice Address - Phone:928-753-4500
Practice Address - Fax:928-753-2220
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0641213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ094601Medicaid
AZ094601Medicaid
AZV09391Medicare UPIN